District Report on Bullying Incidents

(Enclosure No.2A to DepEd Memorandum No. 59, s.
2015)
(To be submitted to the Regional Office on or before June 30)
District Consolidated Report on Incidents of Bullying

School Year 2018 - 2019
Period Covered: JUNE - AUGUST, 2018
District: Zamboanguita
Total Numbers of Public Schools: 17 Total Number of Private Schools : 1
Elementary: 13 Elementary : 1
Secondary: 4 Secondary : 0
Total : 17 Total : 1
Nature of Bullying No. of Bullying Incidence

School Gender- Cyber Total No. of Total No. of
Physical Social Retaliation Male Female Total
Based Bullying Victims Victims
1. Public M F M F M F M F M F
C. Secondary
c. 1 Junior High School
1. Gregorio Elmaga MHS 0 0 0 0 0 0 0 0 0 0 0 0 0
2. Jose Marie Locsin MHS 0 0 0 0 0 0 0 0 0 0 0 0 0
3. Santiago Delmo MHS 1 0 1 2 0 0 0 0 0 0 2 2 4
4. Zamboanguita Science HS 0 0 0 0 0 0 0 0 0 0 0 0 0
c. 2 Senior High School
Sub-Total 1 0 1 2 0 0 0 0 0 0 2 2 4
School Gender- Cyber Total No. Total No.
Physical Social Based Bullying Retaliation of Male of Female Total
Victims Victims
M F M F M F M F M F
II. Private
C. Secondary
1. Décor Carmeli Academy 0 0 0 0 0 0 0 0 0 0 0 0 0
Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0
Note: Bullying as perpetuated by a student against another students which may be
* Physical - unwanted physical contact (punching, shoving, pushing, kicking, tickling, headlocks, etc.)
* Social - refers to any deleberate, repetitive and aggressive social behavior intended to hun or belittle an individual
(name- calling, cunning, labelling, etc.)
* Gender-based - refers to any act that humiliates or exclude 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, on line games, etc.)
Prepared by:
Reviewed and Confirmed by: EVELYN G. TAMPARONG

Principal II
JEANNY M. ABEJERO, Ed. D.
PII/District In Charge
(Enclosure No.2A to DepEd Memorandum No. 59, s. 2015)

Period Covered: SEPTEMBER - DECEMBER, 2018

C. Secondary
c. 2 Senior High Scool
Sub-Total 5 2 1 1 1 0 0 0 0 0 7 3 10
Victims Victims
M F M F M F M F M F
II. Private
C. Secondary
Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0
and gender identity
Prepared by:

Principal II
(Enclosure No.2A to DepEd Memorandum No. 59, s. 2015)

Period Covered: JANUARY - APRIL 5, 2019

C. Secondary
c. 2 Senior High Scool
Sub-Total 5 2 1 1 1 0 0 0 0 0 7 3 10
Victims Victims
M F M F M F M F M F
II. Private
C. Secondary
Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0
and gender identity
Prepared by:

Principal II
(Enclosure No.2B to DepEd Memorandum No. 59, s. 2015)
District Consolidated Report on Incidents of Child Abuse

Period Covered: JUNE - AUGUST, 2018
Secondary: 4 Secondary :
Nature of Abuse No. of Incidence of Child Abuse

Perpetrators
Name of School Verbal/Psyc Total No. Total No.
Physical Sexual hological
of Male of Female School Total
Victims Victims Relatives
Personnel
M F M F M F M F M F
1. PUBLIC
C. Secondary
C.1. Junior High School
C.2. Senior High School

Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0
Name of School Total No. Total No. Perpetrators

Verbal/Psyc of Male of
Physical Sexual
hological Female Total
Victims Victims School
Relatives Personnel
M F M F M F M F M F
1. PRIVATE
C. Secondary
Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0
Note:
* Child Abuse- refers to maltreatment of a child whether habitla 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, pushing, ridicule, threat or 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 (teaching and non-teaching staff)
●No amicable settlement for any acts of child abuse.
Prepared by:

Principal II

School Year : 2018-2019
Period Covered: SEPTEMBER - DECEMBER, 2018

Perpetrators
Personnel
M F M F M F M F M F
1. PUBLIC
C. Secondary

Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0

Physical Sexual
Relatives Personnel
M F M F M F M F M F
1. PRIVATE
C. Secondary
Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0
Note:
Prepared by:

Principal II


Perpetrators
Personnel
M F M F M F M F M F
1. PUBLIC
C. Secondary

Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0

Physical Sexual
Relatives Personnel
M F M F M F M F M F
1. PRIVATE
C. Secondary
Sub-Total 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0
Note:
Prepared by:

Principal II
Enclosure No. 1A to Deped Memorandum No. 59, s.2015
(To be submitted to the Division Office a week after the opening classes after the opening of every school year)
School-Based Report on Incidents of Bullying

School: SANTIAGO DELMO MEMORIAL HIGH SCHOOL
Adress: Maluay, Zamboanguita, Negros Oriental
Period Covered: June - August, 2018
Nature of Bullying Victims Perpetrator Status
Date /Place of Gender- Cyber Resolved/
Physical Social Retaliation Name Age Sex Name Age Sex Action Taken Recommendations
Incident Based Bullying Pending/ Referred
to other agency
M F M F M F M F M F M F M F
6/8/2018 within referred to the
the school ∕ Bernalyn Alingasa 15 ∕ Vincent Partosa 15 ∕ conference Resolved
Discipline
campus
7/11/2018 within Aalheyah Vivien S. Pauline Kyle T. referred to the
the school ∕ 15 ∕ 15 ∕ conference Resolved
Sayre Cabebe Discipline
campus
the school ∕ Jenna Credo 15 ∕ Richard A. dela Paca 15 ∕ conference Resolved
Discipline
campus
8/26/2018 school ∕ referred to the

Joshua Trinidad 15 ∕ Olin de la Pena 15 ∕ conference Resolved
campus Discipline

* Social - refers to any deleberate, repetitive and aggressive social behavior intended to hun or belittle an individual (name- calling, cunning, labelling, etc.)
* Gender-based - refers to any act that humiliates or exclude a person on the basis of perceived or actual sexual orientation and gender identity
Reviewed and Conformed by: EVELYN G. TAMPARONG Prepared by: NENNETTE GRACE C. BANDOLA
SDMHS-Principal II Guidance Counselor Designate
Date: December 10, 2018 Date: December 10, 2018
Period Covered: September - December, 2018
Gender- Cyber
Date /Place of Physical Social Based Bullying
Retaliation Name Age Sex Name Age Sex Resolved/
Action Taken Recommendations
Incident Pending/ Referred
M F M F M F M F M F M F M F to other agency
9/28/2018 referred to the

∕ Algen Rodrriguez 15 ∕ Michelle Sedillo 14 ∕ conference Resolved
classroom Discipline
10/3/2018 inside referred to the

∕ ∕ Josie Fuentes 14 ∕ Jason Elumbra 14 ∕ conference Resolved
the classroom Discipline
10/3/2018 inside referred to the

∕ Jason Elumbra 14 ∕ Josie Fuentes 14 conference Resolved
the classroom Discipline

the school ∕ Angel Marris Datolio 14 ∕ Sukwinder Singh 14 ∕ conference Resolved
Discipline
campus

the school ∕ John Carlo fabillar 14 Jonas Dalagangan 21 ∕ conference Resolved
Discipline
campus

Date /Place of Gender- Cyber
Physical Social
Based Bullying
Retaliation Name Age Sex Name Age Sex Action Taken Recommendations Resolved/
Incident Pending/ Referred
M F M F M F M F M F M F M F to other agency
Date: April 9,2019 Date: April 9,2019
School-Based Report on Incidents of Child Abuse

School: SANTIAGO DELMO MEMORIAL HIGH SCHOOL Classification : (Private/Public) Public
Adress: Maluay, Zamboanguita, Negros Oriental Level: (Kindergarten/Elementary/Secondary): Secondary
Period Covered: June - August, 2018
Nature of Abuse Victims Perpetrators
Status(Resolved/
Sex Sex Relationship
Date /Place of Verbal/ Name (Last Name, First Name (Last Name, First Action Taken Pending/ Referred
Physical Sexual Age (M/ Age (M/ to the Victim
Incident Psychological Name, M.I.) Name, M.I.) to other agenct)
F) F)
M F M F M F M F
NONE NONE
NOTE:
* Child Abuse refers to 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 wel-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, pushing, ridicule, threat or 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 (teaching and non-teaching staff)
No amicable settlement for any acts of child abuse.

Period Covered: September - December, 2018
Status(Resolved/
F) F)
M F M F M F M F
NONE
NONE
NOTE:

Status(Resolved/
F) F)
M F M F M F M F
NONE
NONE
NOTE:
Date: April 9,2019 Date: April 9,2019
D.M. 18, S. 2015 Appendix D
CONSOLIDATED REPORT ON CASES OF CHILDREN -AT-RISK (CAR)

Period Covered: School Year 2018 - 2019
A. Children -At-Risk (CAR)

No. of Students
Classification Action Taken Remarks
Male Female
1. Victim of abuse & sexual, physical,

psychological , mental, economic, and 0 0 N/A N/A
other means)
2. Victim of neglect 0 0 N/A N/A
3. Coming from disfunctional family 0 0 N/A N/A

or without parents or guardian
4. Being member of a gang 0 0 N/A N/A

5. Living in a community with a 0 0 N/A N/A
higher level of criminality
6. Living in a situation of armed 0 0 N/A N/A
conflict
7. Committed a status offense under 0 0 N/A N/A

Setion 57 of RA 9344, as amended
8. Prostituted Children 0 0 N/A N/A

9. Mendicant under PD 2573 0 0 N/A N/A
10. Solvent or Rugby user 0 0 N/A N/A
11. Others 0 0 N/A N/A
B. Description of action taken by the school or division to alleviate the risk factors of
the CAR
Prepared by: Noted by :
NENNETTE GRACE C. BANDOLA EVELYN G. TAMPARONG

Guidance Counselor Designate SDMHS-Principal II
D.M. 18, S. 2015
Appendix F
A. Consolidated Report on Incidents of Children in Conflict with the Law (CICL)

Learner's Reference Sex
Age (M/F) Case/Violation Action Taken Intervention/Diversion Program Remarks
Number
N/A N/A N/A N/A N/A N/A N/A
B. Description or any intervention program or diversion program that the school or division initiated or adopted which facilitated the reintegration of the CICL in the
school and community.

OLA - SH-1
Report: SCHOOL REPORT ON SEXUAL HARASSMENT CASES IN THE DEPARTMENT OF EDUCATION

Region: VII
Name of School NAME OF COMPLAINANT NAME OF RESPONDENT DATE FILED STATUS

SANTIAGO DELMO MEMORIAL
HIGH SCHOOL none none N/A N/A

OLA - SH-1
Report: CONSOLIDATED REPORT ON SEXUAL HARASSMENT CASES IN THE DEPARTMENT OF EDUCATION

Period Covered: #REF!
Region: VII
Name of School NAME OF COMPLAINANT NAME OF RESPONDENT DATE FILED STATUS

A. Public
I. Elementary NONE NONE
II. Secondary NONE NONE
B. Private
I. Elementary NONE NONE
II.Secondary NONE NONE
Prepared by: Reviewed and Confirmed by:
EVELYN G. TAMPARONG JEANNY M. ABEJERO, Ed. D.

Principal II PII/District In Charge
Enclosure A-2
Appendix A
Profiling and Initial Risk Assesment Tools for Children-at-Risk

Part I.
This form will help the Guidance Teacher of Guidance Counselor quickly note down risk factors that will
make the child vulnerable tocoming 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 interventions 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.
I. Child's Identifying Information
Name: Address:
Age: Sex: Date of Birth:
IN School?
Yes Grade Level:
No Highest grade/year level finished:
Caregivers: Father only ________ Mother 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 years old:
Original Position:
II. Individual Factors:
History of substance / Alcohol Abuse Involvement in gang
Involvement in any positive youth development activity, identify: ______________________
Reported incidents of sudden outbursts of anger/irritability exhibited in school
Report or allegations of traumatic experience of the child
Reported recent suicide attempts or suicidal ideation
Child observed in class to be depressed,anxious and out of focus most of the time
Constant somatic complaints
Reported/Noted thoughts disturbances
Types of offenses committed : (Mark with X and indicate how many times reported for every type of
offense committed)
thef Rape
Robbery Homicide
Physical injuries Murder
Sexual Harassment Drug-related offense
Other offenses punishable under penal laws (please indicate)
Family / Community Factors: ( Place check mark)
Child is a victim of abuse, identify __________________ (sexual, physical, emoional, verbal)
Child is a victim of neglect
Child has no parents or no adult guardian in the household
History of parental criminal behavior
History of sibling's criminal behavior
Witness to family / domestic violence
Parents substance abuse
Homeless
Abandoned
Witness to community violence
Presence of support system (family, community, church, school)
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.
Juvenile Justice (JJ)

History of criminal behavior
Current criminal behavior is the first known occurrence
Youth has engaged in multiple delinquent acts in the past year
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's predominantly has peers who engage in delinquent behavior
Youth's primary peer social network are known to engage in criminal behavior
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
whether there is still a need for further investigation or data gathering on the allegations before
referrals are made.
Initial assesment made using this form will not substitute for the proffessional 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
Any allegation of abuse or neglect or any Allegation of physical assault with no

suspicious injury in a non-mobile child visible injury (child is mobile and verbal)
Two or more minor injuries in non-verbal
young childred (including disabled children)
Allegations or suspicions about a serous Any incident / injury triggering concern

injury e.g. a series of apparently accidental
injuries or a minor non-accidental injury
Allegations or suspicions about a sexual
abuse perpetual against a child
Repeated allegations or reasonable Repeated expressed minor concerns

suspicions of non-accidental injury or from one or more sources on
injuries suspicions on non-accidental injury
The child has been traumatized, injured Allegation concerning verbal threats
or neglected as a result of domestic
violence
Repeated allegations involving serious Allegations of emotional abuse including
verbal threats and/ or emotional abuse those that is caused by minor domestic
violence
Allegations/ reasonable suspicions of Allegations of periodic neglect including

serious neglect insufficient supervision; poor hygiene;
clothing or nutrition; failure to seek/ attend
treatments or appointments; young carers
undertaking intimate personal care.
Direct allegation of sexual abuse made by Suspicions of sexual abuse (e.g. medical
child or abuser's confession to such abuse concerns, sexualized behavior, or referral
by concerned relative, neighbor and
Any allegations suggesting connections caregiver.
between sexually abused children in
different families or more than one abuser
An individual inside the child's home

posing a risk to the child (alleged
perpetrator living with the child or who
has daily access to the child / adult alleged
of threatening child to commit crime, etc.)
Any suspicious injury or allegation

volving a child already subject to a child
protection plan or looked afer by a local
authority.
No available parent / carer and child is lef No available parent, child in need of
as abandoned child temporary accomodation and no
specific risk if this need is met
Suspicion that a child has suuffered or is at

risk of significant harm due to fabricated /
induced illness
A child reported to be at-risk of sexual

exploitation or trafficking
Pregnancy in a child
A child at risk of forced marriage
Initial assessment made by:
Printed Name & Signature Designation

Noted by:
NENNETTE GRACE C. BANDOLA Guidance Counselor - Designate

Enclosure A-3
Appendix B
Children In Conflict with the Law (CICL) Intake Form
Division: Region:
Name of School: SANTIAGO DELMO MEMORIAL HIGH SCHOOL
Address: Maluay, Zamboanguita, Negros Oriental
Case No.:
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:
II. Problem Presented (Information on the Reported Offense)
Alleged offense committed by the student(describe incident as reported):
Place and Date of Alleged Commission of Offense:

Name of referring party/ relation to the child:
Name of victim/s (if any): Grade/Level: _____________

Previous Offense reported in school, if any (please indicate date):
III. Actions Taken, if any
IV. Disposition:
Referred and/ or Released to:

LSWDO Name: Contact No.:
PNP Name: Contact No.:
NGO / FBO Name of Organization:
Contact No.:
Released to:
Parents:
Guardians:
Relative/s Name: Contact No.:
Name and Signature of Receiving Party
Address:
Prepared by:
NENNETTE GRACE C. BANDOLA Guidance Counselor - Designate

Noted by:
EVELYN G. TAMPARONG SDMHS-Principal II

ANNEX B
DEPARTMENT OF EDUCATION
INTAKE SHEET
I. INFORMATION:
A. VICTIM
Name:
Date of Birth: Age: Sex:
Grade & Section: Class Adviser:
Parents/Guardian:
Mother: Age:
Occupation:
Address and Contact Number:
Father: Age:
Occupation:
B.COMPLAINANT:
Name:
Relationship to Victim:
C. RESPONDENT:
C -1. If respondent is a School Personnel
Name:
C -2. If respondent is a Student
Name:
Grade & Section: Class Adviser:
Parents/Guardian:
Mother: Age:
Occupation:
Father: Age:
Occupation:
II. DETAILS OF THE CASE:
III. ACTION TAKEN:
IV. RECOMMENDATIONS:
Prepared by:
________________________________
Signature over Printed Name
Designation
Date:

District Report on Bullying Incidents

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District Report on Bullying Incidents

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(Enclosure No.2A to DepEd Memorandum No. 59, s.

District Consolidated Report on Incidents of Bullying

Nature of Bullying No. of Bullying Incidence

Reviewed and Confirmed by: EVELYN G. TAMPARONG

District Consolidated Report on Incidents of Bullying

Nature of Bullying No. of Bullying Incidence

Reviewed and Confirmed by: EVELYN G. TAMPARONG

District Consolidated Report on Incidents of Bullying

Nature of Bullying No. of Bullying Incidence

Reviewed and Confirmed by: EVELYN G. TAMPARONG

District Consolidated Report on Incidents of Child Abuse

Nature of Abuse No. of Incidence of Child Abuse

C.2. Senior High School

Name of School Total No. Total No. Perpetrators

Reviewed and Confirmed by: EVELYN G. TAMPARONG

District Consolidated Report on Incidents of Child Abuse

Nature of Abuse No. of Incidence of Child Abuse

C.2. Senior High School

Name of School Total No. Total No. Perpetrators

Reviewed and Confirmed by: EVELYN G. TAMPARONG

District Consolidated Report on Incidents of Child Abuse

Nature of Abuse No. of Incidence of Child Abuse

C.2. Senior High School

Name of School Total No. Total No. Perpetrators

Reviewed and Confirmed by: EVELYN G. TAMPARONG

School-Based Report on Incidents of Bullying

8/26/2018 school ∕ referred to the

Note: Bullying as perpetuated by a student against another students which may be

9/28/2018 referred to the

10/3/2018 inside referred to the

10/3/2018 inside referred to the

10/4/2108 within referred to the

11/9/2018 within referred to the

School: SANTIAGO DELMO MEMORIAL HIGH SCHOOL

School-Based Report on Incidents of Child Abuse

School-Based Report on Incidents of Child Abuse

School-Based Report on Incidents of Child Abuse

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

School: SANTIAGO DELMO MEMORIAL HIGH SCHOOL

A. Children -At-Risk (CAR)

1. Victim of abuse & sexual, physical,

3. Coming from disfunctional family 0 0 N/A N/A

4. Being member of a gang 0 0 N/A N/A

7. Committed a status offense under 0 0 N/A N/A

8. Prostituted Children 0 0 N/A N/A

Prepared by: Noted by :

NENNETTE GRACE C. BANDOLA EVELYN G. TAMPARONG

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

Prepared by: Noted by :

NENNETTE GRACE C. BANDOLA EVELYN G. TAMPARONG

Report: SCHOOL REPORT ON SEXUAL HARASSMENT CASES IN THE DEPARTMENT OF EDUCATION

Name of School NAME OF COMPLAINANT NAME OF RESPONDENT DATE FILED STATUS

Prepared by: Noted by :

NENNETTE GRACE C. BANDOLA EVELYN G. TAMPARONG

Report: CONSOLIDATED REPORT ON SEXUAL HARASSMENT CASES IN THE DEPARTMENT OF EDUCATION

Name of School NAME OF COMPLAINANT NAME OF RESPONDENT DATE FILED STATUS

Prepared by: Reviewed and Confirmed by:

EVELYN G. TAMPARONG JEANNY M. ABEJERO, Ed. D.

Profiling and Initial Risk Assesment Tools for Children-at-Risk

Juvenile Justice (JJ)

Any allegation of abuse or neglect or any Allegation of physical assault with no

Allegations or suspicions about a serous Any incident / injury triggering concern

Repeated allegations or reasonable Repeated expressed minor concerns