School / District / Municipality: _____________________________________________

Period Covered: _____________________________________________

A. Consolidated Report on Incidents of Children in Conflict with the Law (CICL)

Learner's Reference Number Sex Case / Action Intervention / Diversion

Age
(LRN) (M/F) Violation Taken Program

B. Description of any intervention program or diversion program that the school or division initiated or adopted which fac
in the school and community

__________________________________________________________________________________________________
__________________________________________________________________________________________________

Prepared by: Noted by:

____________________________________ _____________________________
Designation Principal / Superintendent / Regiona
 Appendix F

ention / Diversion Remarks

Program

tiated or adopted which facilitated the reintefration of the CICL

_________________________________________________________
_________________________________________________________

_____________________________
/ Superintendent / Regional Director
(Enclosure No. 3B to DepEd Memorandm No. 55, s. 2015)

(To be submitted to the Office of the Undersecretary for Legal and Legislative Affairs on or before Juy 15)

District / Municipality Consolidated Report on Incidents of C

School Year __________

District / Municipality: ______________________________________

Total Number of Public Schools: ________ Total Number of Private Schools: ________
Elementary: ________ Elementary: ________
Secondary: ________ Secondary: ________
Total: ________ Total: ________

I. Private Schools/Public Schools

Kindergarden Elementary

Nature of Abuse Nature of Abuse

School / District / Municipality
Verbal Verbal
Physical Sexual Perpetrator Physical Sexual
Psychological Psychological

M F M F M F M F M F M F M F

Total
Note:
* Child Abuse refers to the maltreatment of a child, whether habitual or not, which includes any of the following
0 Physical - refers to acts that inflict bodily harm and which subjecs children to perform tasks which are hazaradous to their physical w
0 Sexual - refers to acts that are sexual in nature such as rape, sexual harassment, sexually demeaning remarks, forcing children to wa
0 Psycological - refers to acts or omissions causing or likely to cause mental or emotional suffering to the child which include intimidati
from of punishment, and repeated verbal abuse.

* Relationship to the Victims refer to relatives (father, mother, cousin, etc.) or school personnel (teachers and non-teaching staff)
* No amicable settlement for any acts of child abuse

Reviewed and Confirmed by: _____________________________________

Name / Designation / Date
ncidents of Child Abuse

Total No. of
Secondary Incidents of Abuse
Nature of Abuse

Verbal Total No. Total No.

Perpetrator Physical Sexual Perpetrator of Male of Female
Psychological Victims Victims

M F M F M F M F M F

heir physical well-being;

children to watch obsence publications or shows etc.; and
lude intimidation, harassment, stalking, public ridicule, thret of deduction from grade or merit as a

Prepared by: _______________________________________

Name and Designation
_______________________________________
Date
(Enclosure No. 3A to DepEd Memorandm No. 55, s. 2015)

(To be submitted to the Office of the Undersecretary for Legal and Legislative Affairs on or before Juy 15)

District / Municipality Consolidated Report on

School Year __________

District / Municipality: ______________________________________

Total Number of Public Schools: ________ Total Number of Private Schools: ________
Elementary: ________ Elementary: ________
Secondary: ________ Secondary: ________
Total: ________ Total: ________

I. Private Schools/Public Schools

School / District / Kindergarden Elementary

Municipality
Nature of Bullying Nature of Bullying
Cyber
Gender- Gender- Cyber
Physical Social Retaliation Physical Social
Based Based
Bullying Bullying
M F M F M F M F M F M F M F M F M

Total
Note:
* Use the same form for Publc Schools
* Bullying is perpetrated by a student against anuther student which may be:
* Physical - unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, headloc
* Social - referes to any deliberate, repetitive and aggressive social behavior intended to hurt or belitt
* Gender-Based - refers to any act that humiliates or excludes a person on the basis of perceived or ac
* Cyber Bullying - any bullying done through the use of technology or any electronic means (texting, e

Reviewed and Confirmed by: _____________________________________

Name / Designation
________________________________
Date
ed Report on Incidents of Bullying
__________

Secondary
No. of Bullying Incidents
ng Nature of Bullying
Cyber Total No. Total No.
Gender- Cyber
Retaliation Physical Social Bullying Retaliation
of Male of Female Total
Based Victims Victims
Bullying
F M F M F M F M F M F M F

kling, headlock etc.)

hurt or belitte an individual (name-calling, cursing, labelling, etc.)
erceived or actual sexual orientation and gender identity
ans (texting, email, chatting, online games, etc.)

Prepared by: _______________________________________

Name and Designation
_______________________________________
Date
(To be ssubmitted to the Regional Office on or before July 31, 2014) (Enclosure No. 2 to DepEd Memorandum No. 68, s. 2014

District / Municipality Consolidated Reports on the Submission of School-Based Child Protection or Anti-Bullying Policies
(As of July 2014)

District / Municipality: _______________________________

Total Number of Public Schools Total Number of Private Schools

Elementary: _________ Kindergarden _________
Secondary: _________ Elementary: _________
TOTAL: _________ Secondary: _________
TOTAL: _________

Policy Submitted *

Name of School School I.D. School-Based Child School-Based Child Anti-Bullying

Protection Policy Protection Policy Policy only
with Anti-Bullying without Anti-
Policy Bullying Policy
I. Public
A. Elementary
1

TOTAL: TOTAL: TOTAL:

B. Secondary
1

TOTAL: TOTAL: TOTAL:

II. Private
A. Kindergarden
1

TOTAL: TOTAL: TOTAL:

B. Elementary
1

TOTAL: TOTAL: TOTAL:

C. Secondary
1
 TOTAL: TOTAL: TOTAL:

Instruction:
1. * Put a check (✓) on the kind of policy the school has submitted. Choose one.
2. Get the total no. of policy submitted per category. (Ex. Toral no. of School Base-Child
Protection with Anti-Bullying Policy submitted by public Elem.)
Prepared by:
_______________________________________
Reviewed and Conformed by: _____________________________________ Name and Designation
Name / Designation _______________________________________
________________________________ Date
Date
____

____
 Data on the Involvement on Cases of the Pub
School Year ____________

District / Municipality

Total Number of Enrolment

Male _________
Female _________

Specific Issues and Cas

Total Number
School / District / Municipality of Enrollment Bullying Child Teenage Premarital Marijuana Rugby
Smoking /Durg Use
Labor Pregnancy Sex /Dependency /Solvent

M F M F M F M F M F M F M F M

Total

Reviewed and Conformed by:

Name/Designation
Date
of the Public School Learners
_________

s and Cases
Specific Intervention/Programs
Total Conducted by the
Rugby Child Gang Child Child Others Number Teachers/School Heads/Division
/Solvent Prostitution Member Trafficking Pornography (Specify) of Cases Office
F M F M F M F M F M F M F

Prepared by:

Name/Designation
Date
 Appendix D

CONSOLIDATED REPORT ON CASES OF CHILDREN-AT-RISK (CAR)

School / District / Municipality: ___________________________

Period Covered: ___________________________

I. CHILDREN-AT-RISK (CAR)
Classification No. of Student Action Taken Remarks
Male Female

1. Victim of abuse (sexual,

physical, psycological, 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
Total

II. Description of action taken by the school or division to alleviate the risk factors of CAR:

Prepared by: Noted by:

___________________________ ___________________________
Designation Principal/ Superintendent/ Regional Director
 List of Child Protection Focal Person
(Indicate Region)

Position / Contact No. Email Address

School Name Designation (required) (required)

Prepared by:

Name: (District Focal Person for Child Protection)

Designation:
Contact Number: (required)
Email Address: (required)