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INTAKE SHEET
I. INFORMATION:
A. VICTIM:
Parents:
B. COMPLAINANT:
C. RESPONDENT:
Name: _________________________________
Date of Birth: ___________________________ Age: ____________ Sex: _________
Designation/ Position: _______________________________________________
Address and Contact Number: ________________________________________
_________________________________________________________________
_________________________________________________________________
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Annex “B”
Parents/Guardian:
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.
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:
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