Professional Documents
Culture Documents
INTAKE SHEET
I. INFORMATION:
A. VICTIM:
Name: _____________________________________________
Date of Birth: __________________________ Age: __________ Sex: ___________
Gr. /Yr. and Section: __________________ Adviser: ____________
Parents:
Mother: _______________________ Age: _______
Occupation: ____________________
Address: _______________________
Father: ________________________ Age: _______
Occupation: ____________________
Address and Contact Number: __________________________________________________
___________________________________________________________________________
___________________________________________________________________________
B. COMPLAINANT:
Name: ____________________________________________________
Relationship to Victim: ___________________________________
Address and Contact Number: _________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
C. RESPONDENT:
C-1. If respondent is a School Personnel
Name: _____________________________________________________
Date of Birth: ___________________________ Age: ________________ Sex: ________________
Designation/Position: __________________________________
Address and Contact Number: __________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Schools Division Office
TONDO HIGH SCHOOL
Manila
IV. RECOMMENDATIONS:
1.
2.
3.
Prepared By:
_____________________________
Name over Printed Name
_____________________________
Designation
_____________________________
Date
Schools Division Office
TONDO HIGH SCHOOL
Manila
PART I:
This form will help the guidance teacher or guidance counselor quickly note down risk factors that
make the child vulnerable to coming into conflict with the law. A check mark on those items in
red/bold font require immediate referral of the child to the LSWDO, DSWD or licensed child-caring
agencies and NGOs for further assessment and treatment or intervention planning.
A mark on the other items or factors, other than those in red, require further investigation or data
gathering on the part of the school CPC before referral is made to the LSWDO or DSWD.
Initial assessment made using this form will not substitute for the professional assessment and
judgment of a licensed counselor, licensed child psychologist and licensed social worker.
Name: ____________________________________________________________________________
Age: ________________ Date of Birth: ________________________
Sex: ________________
Address: __________________________________________________________________________
In School? ____ Yes; Grade/Year Level: ____________
____ No; Highest grade/year level finished: _________________
Caregivers: ____ Father only ____ Mother only ____ Father and Mother
____ Others(indicate relationship to child): _________________________________
Caregiver’s source of income/employment and monthly income: _____________________________
No. of Siblings: _________ No. of Siblings below 18 yrs. Old: _______________
Ordinal Position: ___________
Schools Division Office
TONDO HIGH SCHOOL
Manila
Types of offenses committed (Mark with X and indicate how many times reported for every type of
offense committed)
_______________ Theft
_______________ Robbery
_______________ Physical injuries
_______________ Sexual harassment
_______________ Rape
_______________ Homicide
_______________ Murder
_______________ Drug-related offense
_______________ Other offenses punished under penal laws (please indicate)
Family/community factors:
_____ Child is a victim of abuse, identity ________________ (sexual, physical, emotional, verbal)
_____ Child is a victim of neglect
_____ Child has no parents or no adult guardian in the household
_____ History of parental criminal behavior
Schools Division Office
TONDO HIGH SCHOOL
Manila
School behavior
_____ Child is behaving well in school
_____ Child is a victim of bullying in school
_____ Child has been observed to have moderate behavior problems in school
_____ Child had severe problems with behavior in school. Child has been reported for bullying in
school.
Seriousness
_____ Youth has engaged only in status violations or violations of local ordinances
_____ Youth has engaged in criminal behavior
_____ Youth has engaged in criminal behavior that places other citizens at risk of significant physical
harm
Peer Influences
_____ Youth’s primary peer social network does not engage in delinquent behavior
_____ Youth predominantly has peers who engage in delinquent behavior
_____ Youth’s primary peer social network are known to engage in criminal behavior
_________________________________
Indicators were based on the Juvenile Justice Module of the Child and Adolescent Needs and Strengths
Manual. Preda Foundation (1999)
Schools Division Office
TONDO HIGH SCHOOL
Manila
PART II:
The table below further provides a non-exhaustive list of examples of evidence which would
suggest that a student has met the threshold for an immediate referral to the proper authorities
(LSWDO, Licensed SW of accredited and duly-licensed child caring agency, or to the DSWD CIU) or
Anythere
whether allegation
is still aofneed
abuse
fororfurther
neglectinvestigation
or any or data gathering on the allegations before
suspicious
referrals are made. injury in a non-mobile child
Initial assessment made using this form will not substitute for the professional assessment and
judgment of a licensed counselor, licensed child psychologist and licensed social worker.
Referral to LSWDO for immediate intervention within 8 hours
Initial Assessment: For further investigation before referral to LSWDO or DSWD within 24 hours
The child has been traumatized, injured Allegation concerning verbal threats
or neglected as a result of domestic
violence
Allegations of emotional abuse including
Repeated allegations involving serious that caused by minor domestic violence
verbal threats and/or emotional abuse
Schools Division Office
TONDO HIGH SCHOOL
Manila
Direct allegation of sexual abuse made Suspicions of sexual abuse (e.g. medical
by child or abuser’s confession to such concerns, sexualized behavior, or referral
abuse by concerned relative, neighbor and
caregiver)
Any allegation suggesting connections
between sexually abused children in
different families or more than one
abuser.
Pregnancy in a child
____________________________________ _________________________
Name and Signature Designation
Noted By:
____________________________________ _________________________
Name and Signature Designation
Schools Division Office
TONDO HIGH SCHOOL
Manila
I. Identifying Information
Name: _____________________________________________________________
Nickname: __________________
Age: ___________ Sex: _________________
Date of Birth: _____________________
Place of Birth: _____________________
Address: ____________________________________________________________
Grade/Year Level & Section: ____________________________________________
Class Adviser: ________________________________________________________
Parents/Guardian Information:
Parents/Guardian: ____________________________________________________
Address: ____________________________________________________________
Contact No’s: ________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
IV. Disposition:
Released to:
Parents
Guardian
Relative/s Name: ________________________________ Contact No: __________________
____________________________________
Name and Signature of Receiving Copy
Address: ________________________________________________
Prepared by:
Schools Division Office
TONDO HIGH SCHOOL
Manila
________________________________ _________________________
Name and Signature Designation
Noted by:
________________________________ _________________________
Name and Signature Designation
This form should be completed by fully trained and designated staff of the
school. Original copy shall be maintained in the school and shall form part
of the client’s confidential records.
Instructions Any information contained herein and the rest of the records of the client
shall be held in strict confidence. No information from this card shall be
shared to anyone except to service provider and as may be authorized.
Attach additional pages with continued narrative, if needed.
To: _______________________________________________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please refer to attached report/ intake form /case summary for more information.
Referred by:
____________________________________ ______________________________
Signature over Printed Name Designation
____________________________________
Date Accomplished
Schools Division Office
TONDO HIGH SCHOOL
Manila
For the best interest of (name of offender) and the school/community, the following shall be
undertaken:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
For the social worker or Local Social Welfare and Development Officer (LSWDO):
Schools Division Office
TONDO HIGH SCHOOL
Manila
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Prepared by:
_____________________________________
Guidance Counselor/RJP Secretary
Conformed:
Noted by:
________________________________
Principal/RJP Chairperson
Schools Division Office
TONDO HIGH SCHOOL
Manila
Note: Bullying is perpetrated by a student against another student which may be:
Physical-unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling,
headlocks, etc.)
Social-refers to any deliberate, repetitive and aggressive social behavior intended to hurt or
belittle an individual (name-calling, cursing, labelling, etc.)
Gender-based – refers to any act that humiliates or excludes a person on the basis of
perceived or actual sexual orientation and gender identity.
Cyber Bullying – any bullying done through the use of technology or any electronic means
(texting, email, chatting, online games, etc.)
Date: ______________________
Date: ______________________
School-Based Report on Incidents of Child Abuse
School Year: _____________
Schools Division Office
TONDO HIGH SCHOOL
Manila
TOTAL
Note:
Child Abuse refers to the maltreatment of a child, whether habitual or not, which includes any of the
following:
Physical-refers to acts that inflict bodily harm and which subjects children to perform tasks
which are hazardous to their physical well-being;
Sexual-refers to acts that are sexual in nature such as rape, sexual harassment, sexually
demeaning remarks, forcing children to watch obscene publications or shows, etc.; and
Psychological – refers to acts or omissions causing or likely to cause mental or emotional
suffering to the child which include intimidation, harassment, stalking, public ridicule, threat
of deduction from grade or merit as a form of punishment, and repeated verbal abuse.
- Relationship to the victim refers to relatives (father, mother, cousin, etc.) or school
personnel (teachers and non-teaching staff)
- No amicable settlement for any acts of child abuse
School/Division/Region: _________________________________
Period Covered: _________________________________
I. CHILDREN-AT-RISK (CAR)
No. of Students
Classification Action Taken Remarks
Male Female
1. Victim of Abuse (sexual, physical,
psychological, mental, economic,
and other mean)
2. Victim of Neglect
3. Coming from a dysfunctional
family or without parent or guardian
4. Being member of a gang
5. Living in a community with a
higher level of criminality
6. Living in a situation of armed
conflict
7. Committed a status Offense
under Section 57 of RA 9344, as
amended
8. Prostituted Children
9. Mendicant under PD 1563
10. Solvent/Rugby User
11. Others
II. Description of action taken by the school or division to alleviate the risk factors of the CAR:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________ ____________________________________
Designation Principal/Superintendent/Regional Director
Schools Division Office
TONDO HIGH SCHOOL
Manila
School/Division/Region: __________________________________
Period Covered: ________________________________________
B. Description of any intervention program or diversion program that the school or division initiated or adapted which facilitated the reintegration of
the CICL in the school and community
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________ _______________________________________
Designation Principal/Superintendent/Regional Director
Schools Division Office
TONDO HIGH SCHOOL
Manila
Instruction: This checklist is designed to monitor and evaluate the compliance of the school in the implementation of
DepEd Order No. 40, s. 2012 and DepEd Order No. 55, s. 2013
Findings will be based simply on the presence or absence of the requirement as stated in each item and shall be the
basis for a plan of action by the school and the Schools Division Office.
P A
1. The school has a written school-based child protection and/or anti-bullying policies
2. There is a code of conduct incorporated in the school-based child protection or anti-bullying
policy for the following:
a) Students
b) School Administrators
c) Non-Teaching Personnel (guards, maintenance, etc.)
d) Teachers
e) Visitors (Parents, Alumni, etc.)
f) Off-Campus activities such as field trips, camping’s, etc.
3. The code of conduct has specific provisions to address potential risks to students such as:
a) Disregarding abusive situation or behavior against children;
b) Employing children as house helper or asking students to care for
teacher’s children while in school;
c) Relating with children in private for personal matters like student-
teacher as “text mates” or Facebook friends;
d) Going out with students after school such as watching movies;
e) Using green jokes or jokes with double meaning in the class; and
f) Cultural beliefs (marrying children because it is acceptable based on
one’s culture/religion, amicable settlement on child abuse cases)
4. Promotion or information dissemination of the school-based child protection and/or anti-
bullying policies is done during school opening for:
a) Students
b) Teachers
c) Non-Teaching Personnel
d) Parents
5. There are written procedures to guide in conducting disciplinary proceedings in cases of
offenses committed by pupils, students, or learners.
Schools Division Office
TONDO HIGH SCHOOL
Manila
6. The School has adopted a conflict resolution mechanism that respects the rights of indigenous
peoples, provided that they conform to child’s rights and the Department issuances on child
protection.
7. There is an established system for identifying students who may be suffering from significant
harm based on physical, emotional, or behavioral signs.
8. Has developed and implemented a school-based referral and monitoring system to address
child abuse and bullying cases.
9. There is an existing record of all proceedings related to bullying and child abuse cases using
the Intake Sheet (Annex B of DO 40, s. 2012 or Appendix B of DO 18, s. 2015) as appropriate.
10. Records related to complex cases of child abuse and bullying using the Intake Sheets (Annex A
of DO 40, s. 2012 or Appendix B of DO 18, s. 2015) are well-kept and separate from simple
cases.
11. The school has submitted its consolidated reports on bullying and child abuse cases to the
Division Office a week after the opening of each school year.
12. Has mapped out available resources in their community for possible linkages or networking
for cases needing referrals, etc.
13. Has an active coordination with WPCD, DSWD, and other government and Non-Government
Organizations (NGO).
14. Has a clear policy on the use of positive and non-violent discipline for children.
15. There is an organized Child Protection Committee (CPC) in the school.
16. There is an annual capacity building activities for the members of the CPC:
a) Guidance Counselor/Designated Guidance Teacher
b) Representative of the Students
c) Representative of the Parents
d) Representative of the Barangay
e) Representative of the Teachers
17. The CPC is meeting regularly to discuss appropriate interventions and/or responses to school
problems on bullying and child abuse cases and other concerns.
18. The school with its CPC has initiated information dissemination programs and organized
activities for the protection of children from abuse, exploitation, violence, harm, and bullying.
19. There is a strong student participation in the promotion of child protection and anti-bullying
policies of the school.
20. There is a feedback mechanism in the school to monitor the implementation of the Child
Protection and/or Anti-Bullying policies.
Respectfully Submitted:
_________________________________________________
Signature above Printed Name of School Head
Schools Division Office
TONDO HIGH SCHOOL
Manila
Division: __________________
Total Number of Public Schools: ________ Total Number of Private Schools: ________
Elementary: ________ Elementary: _________
Secondary: _________ Secondary: __________
Total: ________ Total: ________
Sub-Total
(Public Elementary):
B. Secondary
1.
2.
Sub-Total
(Public Secondary)
II. Private
A. Kindergarten
1.
2.
Sub-Total
(Private Kindergarten)
B. Elementary
1.
2.
Sub-Total
(Private Elementary)
C. Secondary
Schools Division Office
TONDO HIGH SCHOOL
Manila
1.
2.
Sub-Total
(Private Secondary)
Total:
Note: Bullying is perpetrated by a student against another student, which may be:
Physical-unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, headlocks, etc.)
Social-refers to any deliberate, repetitive and aggressive Social behavior intended to hurt or belittle an
individual (name-calling, cursing, labelling, etc.)
Gender-Based – refers to any act that humiliates or excludes a person on the basis of perceived or actual
sexual orientation and gender identity.
Cyber Bullying-any bullying done through the use of technology or any electronic means (texting, email,
chatting, online games, etc.).
____________________________ _______________________________
Name and Designation Name and Designation
____________________________ _______________________________
Date Date
Schools Division Office
TONDO HIGH SCHOOL
Manila
Division: __________________
Total Number of Public Schools: ________ Total Number of Private Schools: ________
Elementary: ________ Elementary: _________
Secondary: _________ Secondary: __________
Total: ________ Total: ________
Sub-Total
(Public Elementary)
B. Secondary
1.
2.
Sub-Total
(Public Secondary)
II. Private
A. Kindergarten
1.
2.
Sub-Total
(Private Kindergarten)
B. Elementary
1.
2.
Sub-Total
(Private Elementary)
Schools Division Office
TONDO HIGH SCHOOL
Manila
C. Secondary
1.
2.
Sub-Total
(Private Secondary)
Total:
Note:
Child Abuse refers to the maltreatment of a child, whether habitual or not, which includes any of the following:
Physical-refers to acts that inflict bodily harm and which subjects children to perform tasks which are
hazardous to their physical well-being;
Sexual-refers to acts that are sexual in nature such as rape, sexual harassment, sexually demeaning remarks,
forcing children to watch obscene publications or shows, etc.; and
Psychological – refers to acts or omissions causing or likely to cause mental or emotional suffering to the
child which include intimidation, harassment, stalking, public ridicule, threat of deduction from grade or
merit as a form of punishment, and repeated verbal abuse.
- Relationship to the victim refers to relatives (father, mother, cousin, etc.) or school personnel (teachers and
non-teaching staff)
- No amicable settlement for any acts of child abuse
_________________________________ ___________________________________
Name and Designation Name and Designation
_________________________________ ___________________________________
Date Dat
Schools Division Office
TONDO HIGH SCHOOL
Manila
Division: __________________
Total Number of Public Schools: ________ Total Number of Private Schools: ________
Elementary: ________ Elementary: _________
Secondary: _________ Secondary: __________
Total: ________ Total: ________
Policy Submitted
School-Based School-Based
Child Child Anti-
Name of School School I.D. Protection Protection bullying
Policy with Policy without Policy
Anti-Bullying Anti-bullying Only
Policy Policy
I. Public
A. Public
1.
Instruction:
1. * Put a check (√) on the kink pf policy the school has submitted. Choose one.
2. Get the total no. of policy submitted per category. (Ex. Total No. of School Base-Based Protection
with Anti-Bullying Policy submitted by Public Elem.)
Prepared by:
______________________________
Designation
______________________________
Date
_______________________________
Designation
_______________________________
Date
Schools Division Office
TONDO HIGH SCHOOL
Manila
Division: _____________________
School Year: ____________________
Date of Submission: _______________________
Submitted by:
________________________________
Signature over Printed Name
________________________________
Designation