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Annex “B”

Republic of the Philippines


Department of Education
Region IV-A CALABARZON
Division of Quezon
CABAY NATIONAL HIGH SCHOOL
Cabay, Tiaong, Quezon

INTAKE SHEET
I. INFORMATION:

A. VICTIM:

Name: LADYLEN GOMEZ BALBA

Date of Birth: NOVEMBER 23, 2000 Age: 16 Sex: FEMALE

Gr./Yr and Section: GRADE 10 DAU Adviser: CLARISSA C. REYES

Parents:

Mother: SEVILLA PANGANIBAN GOMEZ Age: _________


Occupation: HOUSEWIFE
Address: DEL ROSARIO, TIAONG, QUEZON
Father: DANILO ATIENZA BALBA Age: _________
Occupation: LABORER
Address and Contact Number: DEL ROSARIO, TIAONG, QUEZON

B. COMPLAINANT:

Name: DANILO A. BALBA


Relationship to Victim: FATHER

C. RESPONDENT:

C-1. If respondent is a School Personnel

Name: _________________________________
Date of Birth: ___________________________ Age: ____________ Sex: _________
Designation/ Position: _______________________________________________
Address and Contact Number: ________________________________________
_________________________________________________________________
_________________________________________________________________

C-2. If respondent is a Student


Name: LADYLEN GOMEZ BALBA

Date of Birth: NOVEMBER 23, 2000 Age: 16 Sex: FEMALE

Gr./Yr and Section: GRADE 10 DAU Adviser: CLARISSA C. REYES

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Annex “B”

Parents/Guardian:

Mother: SEVILLA PANGANIBAN GOMEZ Age: _________


Occupation: HOUSEWIFE
Address: DEL ROSARIO, TIAONG, QUEZON
Father: DANILO ATIENZA BALBA Age: _________
Occupation: LABORER
Address and Contact Number: DEL ROSARIO, TIAONG, QUEZON

II. DETAILS OF THE CASE:

It was October 13, 2017 when Mr. Jeremy P. Punzalan, Grade 10 Pili and Ms. Ladylen G. Balba,
Grade 10 Dau had an incident of quarelling inside of Grade 10 Dau’s classroom and was ended
of slapping Ms. Ladylen G. Balba’s face by Mr. Jeremy P. Punzalan. Mr. Jeremy P. Punzalan left
the school but when Ms. Ladylen G. Balba went out during lunch break, Mr. Jeremy P.
Punzalan returned from his house. By that time, Ms. Ladylen G. Balba while waiting for a jeep
going home was caught and attacked again by Mr. Jeremy P. Punzalan hitting her head several
times, throwing bulgar words to Ms. Ladylen G. Balba at the same time. In order to settle the
untoward incident, both parents were asked to come to school to discuss and made report
what had happen. The father of Ms. Ladylen G. Balba gave another chance to Mr. Jeremy P.
Punzalan in one condition that he will not do it again, otherwise he will be sue for a case of
bullying, physical injury, grave misconduct, public scandal and the like.

III. ACTION TAKEN:


1. Call the parents of the students involved and had a dialog between the victim and the
offending student.
2. Discusses the duties and responsibilities especially the code of conduct for students that
the offending student’s violated.
3. The school head together with the child protection committee or disciplining committee
discusses the issue and arrived at one decision to give the offending student disciplinary
actions.

IV. RECOMMENDATIONS:
1. Advised the parent of the offending student to give counseling to his son for his
misconduct.
2. The offending student will not be admitted in class for one week as part of school’s
disciplinary actions.
3. The offending student is advised to undergo Alternative Delivery Mode (Modular)
Learning.

Prepared by:

MA. IRENE D. RECIO


Guidance Counselor
October 16, 2017

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