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    Guidance 3 CPP-Intake-Sheet

    Uploaded by

    Cristita malabed

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Guidance 3 CPP-Intake-Sheet

    Uploaded by

    Cristita malabed
    2 views2 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2 views2 pages

    Guidance 3 CPP-Intake-Sheet

    Uploaded by

    Cristita malabed

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Annex “B”

    INTAKE SHEET
    I. INFORMATION:

    A. VICTIM:

    Name: ________________________________________________ Date of Birth:


    ___________________________
    Age: ________ Sex: _______ Gr./Yr and Section: ____________ Adviser:
    __________________________________

    Parents:

    Mother: ________________________________________ Age: ________ Occupation:


    ______________________
    Address: and Contact Number:
    ________________________________________________________________________

    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:
    _________________________________________________________________________

    C-2. If respondent is a Student

    Name: ___________________________________________________ Date of Birth:


    ________________________
    Age: ________ Sex: _______ Gr./Yr and Section: _______________ Adviser:
    ______________________________

    Parents/Guardian:

    Mother: ________________________________________ Age: ________ Occupation:


    ______________________
    Address: and Contact Number:
    ________________________________________________________________________

    Father: _________________________________________ Age: _________ Occupation:


    ______________________
    Address and Contact Number:
    _________________________________________________________________________
    II. DETAILS OF THE CASE:

    III. ACTION TAKEN:

    IV. RECOMMENDATIONS:

    Prepared by:

    ___________________________________________________
    Signature over Printed Name

    ___________________________________________________
    Designation

    _______________________
    Date

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