Intake-sheet-form-tondo-high.docx

Schools Division Office TONDO HIGH SCHOOL Manila

INTAKE SHEET I. INFORMATION: A. VICTIM: Name: _____________________________________________ Date of Birth: __________________________ Age: __________ Sex: ___________ Gr. /Yr. and Section: __________________

Adviser: ____________

Parents: Mother: _______________________

Age: _______

Occupation: ____________________ Address: _______________________ 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: __________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Schools Division Office TONDO HIGH SCHOOL Manila

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: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

Schools Division Office TONDO HIGH SCHOOL Manila

III. ACTION TAKEN: 1. 2. 3. 4.

IV. RECOMMENDATIONS: 1. 2. 3.

Prepared By: _____________________________ Name over Printed Name _____________________________ Designation _____________________________ Date

Schools Division Office TONDO HIGH SCHOOL Manila

Profiling and Initial Risk Assessment Tools for Children-at-Risk PART I: This form will help the guidance teacher or guidance counselor quickly note down risk factors that make the child vulnerable to coming 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 intervention 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: ____________________________________________________________________________ Age: ________________

Date of Birth: ________________________

Sex: ________________ Address: __________________________________________________________________________ In School?

Caregivers:

____ Yes;

Grade/Year Level: ____________

____ No;

Highest grade/year level finished: _________________

____ Father only

____ Mother only

____ Father and Mother

____ Others(indicate relationship to child): _________________________________ Caregiver’s source of income/employment and monthly income: _____________________________ No. of Siblings: _________ Ordinal Position: ___________

No. of Siblings below 18 yrs. Old: _______________

Schools Division Office TONDO HIGH SCHOOL Manila

II. Individual factors:

_____ History of substance/Alcohol abuse _____ Involvement in gangs _____ 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) _______________ Theft _______________ Robbery _______________ Physical injuries _______________ Sexual harassment _______________ Rape _______________ Homicide _______________ Murder _______________ Drug-related offense _______________ Other offenses punished under penal laws (please indicate)

Family/community factors: _____ Child is a victim of abuse, identity ________________ (sexual, physical, emotional, verbal) _____ Child is a victim of neglect _____ Child has no parents or no adult guardian in the household _____ History of parental criminal behavior

Schools Division Office TONDO HIGH SCHOOL Manila _____ History of sibling’s criminal behavior _____ Witness to family/domestic violence _____ Parent 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 predominantly has peers who engage in delinquent behavior _____ Youth’s primary peer social network are known to engage in criminal behavior _________________________________ Indicators were based on the Juvenile Justice Module of the Child and Adolescent Needs and Manual. Preda Foundation (1999)

Strengths

Schools Division Office TONDO HIGH SCHOOL Manila

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 Anythere allegation abuse neglectinvestigation or any whether is still aofneed fororfurther or data gathering on the allegations before suspicious injury in a non-mobile child referrals are made. 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. Referral to LSWDO for immediate intervention within 8 hours Initial Assessment: For further investigation before referral to LSWDO or DSWD within 24 hours Allegation of physical assault with no visible injury (child is mobile and verbal) Two or more minor injuries in non-verbal young children (including disabled children)

Allegations or suspicions about a serious injury

Any incident/injury triggering concern e.g. a series of apparently accidental injuries or a minor non-accidental injury

Allegations or suspicions about a sexual abuse perpetrated against a child

Repeated allegations or reasonable suspicions of non-accidental injury or injuries

The child has been traumatized, injured or neglected as a result of domestic violence Repeated allegations involving serious verbal threats and/or emotional abuse

Repeated expressed minor concerns from one or more sources on suspicions on non-accidental injury

Allegation concerning verbal threats Allegations of emotional abuse including that caused by minor domestic violence

Schools Division Office TONDO HIGH SCHOOL Manila

Allegations/reasonable suspicions of serious neglect

Direct allegation of sexual abuse made by child or abuser’s confession to such abuse Any allegation suggesting connections between sexually abused children in different families or more than one abuser.

Allegations of periodic neglect including insufficient supervision; poor hygiene; clothing or nutrition; failure to seek/attend treatments or appointments; young carers undertaking intimate personal care. Suspicions of sexual abuse (e.g. medical concerns, sexualized behavior, or referral by concerned relative, neighbor and caregiver)

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 involving a child already subject to a child protection plan or looked after by a local authority. No Available parent/carer and child is left abandoned child

Suspicion that a child has suffered or is at risk of significant harm due to fabricated/induced illness.

No available parent, child in need of temporary accommodation and no specific risk if this needs is met

Schools Division Office TONDO HIGH SCHOOL Manila

A child reported to be at-risk of sexual exploitation of trafficking

Pregnancy in a child

A child at risk of forced marriage

Initial assessment made by: ____________________________________ Name and Signature

_________________________ Designation

Noted By: ____________________________________ Name and Signature

_________________________ Designation

Schools Division Office TONDO HIGH SCHOOL Manila

Children in Conflict with the Law (CICL) Intake Form Division: __________________ Region: __________________ Name of School: _________________________________________________________ Address: _______________________________________________________________ Case. No: _____________________ Date: ________________________

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): __________________________________________________________________________________ __________________________________________________________________________________

Schools Division Office TONDO HIGH SCHOOL Manila __________________________________________________________________________________ __________________________________________________________________________________ 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 Guardian Relative/s Name: ________________________________ Contact No: __________________

____________________________________ Name and Signature of Receiving Copy Address: ________________________________________________

Prepared by:

Schools Division Office TONDO HIGH SCHOOL Manila

________________________________ Name and Signature

_________________________ Designation

Noted by:

________________________________ Name and Signature

_________________________ Designation

REFERRAL FOR SERVICE

Instructions

This form should be completed by fully trained and designated staff of the school. Original copy shall be maintained in the school and shall form part of the client’s confidential records. Any information contained herein and the rest of the records of the client shall be held in strict confidence. No information from this card shall be shared to anyone except to service provider and as may be authorized. Attach additional pages with continued narrative, if needed.

Case No: _________________ To: _______________________________________________________________________________ Address: __________________________________________________________________________ Contact Person: ____________________________________________________________________ Name of Student: ___________________________________________________________________ Age: __________

Sex: _________

Address: ___________________________________

Reason/s for Referral: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Specific Service/s Requested: __________________________________________________________________________________ __________________________________________________________________________________

Schools Division Office TONDO HIGH SCHOOL Manila __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Please refer to attached report/ intake form /case summary for more information.

Feedback is requested. Please send to: Referring Party/School: ______________________________________________________________ Address: __________________________________________________________________________ Cellphone No: ____________________ Landline No: ________________________________ E-mail Address: ______________________________ Fax No: _____________________________ Contact Person: ____________________________________________________________________

Referred by:

____________________________________ Signature over Printed Name

____________________________________ Date Accomplished

______________________________ Designation

Schools Division Office TONDO HIGH SCHOOL Manila

RESTORATIVE JUSTICE AGREEMENT FORM I. Background of the Incident II. Statement of Agreement For the best interest of (name of offender) and the school/community, the following shall be undertaken: For the student-offender: (Example: make a research work on the ill-effects of smoking) __________________________________________________________________________________ __________________________________________________________________________________ For the parents of the student-offender: __________________________________________________________________________________ __________________________________________________________________________________ For the teacher-adviser/Guidance Counselor or Guidance Teacher: __________________________________________________________________________________ __________________________________________________________________________________ For the social worker or Local Social Welfare and Development Officer (LSWDO):

Schools Division Office TONDO HIGH SCHOOL Manila __________________________________________________________________________________ __________________________________________________________________________________ For the victim and his/her parent/s (when appropriated): __________________________________________________________________________________ This agreement will be implemented starting _________________ until ___________________.

Prepared by:

_____________________________________ Guidance Counselor/RJP Secretary

Conformed:

_________________________ ________________________ (Student-offender) (Parent)

Noted by:

________________________________ Principal/RJP Chairperson

____________________________ LSWDO/Social Worker

Schools Division Office TONDO HIGH SCHOOL Manila

School-Based Report on Incidents of Bullying School Year: ________________ School: _______________________________________ (Private/Public) __________________________________ Address: _____________________________________ (Kindergarten/Elementary, Secondary) ______________________ Date/ Place of Incide nt

Nature of Bullying Cyb Gen Phy So er Retal dersica cia Bull iatio Bas l l yin n ed g

Victims Na m e

A g e

Se x (M /F)

Classification: Level:

Perpetrator Na m e

A g e

Se x (M /F)

Act ion tak en

Recomm endation

Status (Resolved /Pending/ Referred to other agency)

Note: Bullying is perpetrated by a student against another student which may be:  Physical-unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, headlocks, etc.)  Social-refers to any deliberate, repetitive and aggressive social behavior intended to hurt or belittle an individual (name-calling, cursing, labelling, etc.)  Gender-based – refers to any act that humiliates or excludes 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, online games, etc.)

Reviewed and Conformed by: _____________________________ Prepared by: _____________________________ Name and Designation Name/Designation

Date:

Date: ______________________ ______________________ School-Based Report on Incidents of Child Abuse School Year: _____________

Schools Division Office TONDO HIGH SCHOOL Manila School: _______________________________________ (Private/Public) ___________________________ Address: ______________________________________ (Kindergarten/Elementary, Secondary) _______________

Date of Incident

Nature of Abuse Verbal/ Physical Sexual Psychologic al

Victims Name (Last Name, Age First Name, M.I)

Classification: Level:

Sex (M/F)

Perpetrators Name (Last Name, Age First Name, M.I)

TOTAL Note: Child Abuse refers to the 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 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, public ridicule, threat of 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 (teachers and non-teaching staff) No amicable settlement for any acts of child abuse

Reviewed and Conformed by: ___________________________________ Prepared by: _____________________________________ Name and Designation/ Date Name/Designation / Date

Sex (M/F)

Schools Division Office TONDO HIGH SCHOOL Manila

CONSOLIDATED REPORT ON CASES OF CHILDREN-AT-RISK (CAR) School/Division/Region: _________________________________ Period Covered: _________________________________

I. CHILDREN-AT-RISK (CAR) Classification

No. of Students Male Female

Action Taken

Remarks

1. Victim of Abuse (sexual, physical, psychological, 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

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

Prepared by:

Noted by:

Schools Division Office TONDO HIGH SCHOOL Manila ________________________ Designation

____________________________________ Principal/Superintendent/Regional Director

Schools Division Office TONDO HIGH SCHOOL Manila

School/Division/Region: __________________________________ Period Covered: ________________________________________ A. Consolidated Report on incidents of Children in Conflict with the Law (CICL) Learner’s Sex Reference Number Age Case/Violation Action Taken (M/F) (LRN)

Intervention/Diversion Program

Remarks

B. Description of any intervention program or diversion program that the school or division initiated or adapted which facilitated the reintegration of the CICL in the school and community _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________

Prepared by:

Noted by:

_______________________________________ Designation

_______________________________________ Principal/Superintendent/Regional Director

Schools Division Office TONDO HIGH SCHOOL Manila

SCHOOL-BASED CHILD PROTECTION/ANTI-BULLYING POLICY IMPLEMENTATION CHECKLIST (Based on Annex 2B of DepEd Order No. 44, s.2015: Guidelines on the Enhanced School Improvement Planning (SIP) Process and the School Report Card (SRC)) Name of School: _________________________________________ Address: _______________________________________________ Schools District: _________________________________________ Schools Division: _________________________________________ Date of Submission: _____________________________________ Instruction: This checklist is designed to monitor and evaluate the compliance of the school in the implementation of DepEd Order No. 40, s. 2012 and DepEd Order No. 55, s. 2013 Tick the appropriate box that corresponds to your observation P – Present or In Place A – Absent or Not In Place Findings will be based simply on the presence or absence of the requirement as stated in each item and shall be the basis for a plan of action by the school and the Schools Division Office. P 1. The school has a written school-based child protection and/or anti-bullying policies 2. There is a code of conduct incorporated in the school-based child protection or anti-bullying policy for the following: a) Students b) School Administrators c) Non-Teaching Personnel (guards, maintenance, etc.) d) Teachers e) Visitors (Parents, Alumni, etc.) f) Off-Campus activities such as field trips, camping’s, etc. 3. The code of conduct has specific provisions to address potential risks to students such as: a) Disregarding abusive situation or behavior against children; b) Employing children as house helper or asking students to care for teacher’s children while in school; c) Relating with children in private for personal matters like studentteacher as “text mates” or Facebook friends; d) Going out with students after school such as watching movies; e) Using green jokes or jokes with double meaning in the class; and f) Cultural beliefs (marrying children because it is acceptable based on one’s culture/religion, amicable settlement on child abuse cases) 4. Promotion or information dissemination of the school-based child protection and/or antibullying policies is done during school opening for: a) Students b) Teachers c) Non-Teaching Personnel d) Parents 5. There are written procedures to guide in conducting disciplinary proceedings in cases of offenses committed by pupils, students, or learners.

A

Schools Division Office TONDO HIGH SCHOOL Manila 6. The School has adopted a conflict resolution mechanism that respects the rights of indigenous peoples, provided that they conform to child’s rights and the Department issuances on child protection. 7. There is an established system for identifying students who may be suffering from significant harm based on physical, emotional, or behavioral signs. 8. Has developed and implemented a school-based referral and monitoring system to address child abuse and bullying cases. 9. There is an existing record of all proceedings related to bullying and child abuse cases using the Intake Sheet (Annex B of DO 40, s. 2012 or Appendix B of DO 18, s. 2015) as appropriate. 10. Records related to complex cases of child abuse and bullying using the Intake Sheets (Annex A of DO 40, s. 2012 or Appendix B of DO 18, s. 2015) are well-kept and separate from simple cases. 11. The school has submitted its consolidated reports on bullying and child abuse cases to the Division Office a week after the opening of each school year. 12. Has mapped out available resources in their community for possible linkages or networking for cases needing referrals, etc. 13. Has an active coordination with WPCD, DSWD, and other government and Non-Government Organizations (NGO). 14. Has a clear policy on the use of positive and non-violent discipline for children. 15. There is an organized Child Protection Committee (CPC) in the school. 16. There is an annual capacity building activities for the members of the CPC: a) Guidance Counselor/Designated Guidance Teacher b) Representative of the Students c) Representative of the Parents d) Representative of the Barangay e) Representative of the Teachers 17. The CPC is meeting regularly to discuss appropriate interventions and/or responses to school problems on bullying and child abuse cases and other concerns. 18. The school with its CPC has initiated information dissemination programs and organized activities for the protection of children from abuse, exploitation, violence, harm, and bullying. 19. There is a strong student participation in the promotion of child protection and anti-bullying policies of the school. 20. There is a feedback mechanism in the school to monitor the implementation of the Child Protection and/or Anti-Bullying policies. Respectfully Submitted: _________________________________________________ Signature above Printed Name of School Head

Schools Division Office TONDO HIGH SCHOOL Manila

DIVISION CONSOLIDATED REPORT ON INCIDENTS OF BULLYING SCHOOL YEAR ______________ (Based on Enclosure 2A of DepEd Memorandum No. 59, s. 2015)

Division: __________________ Total Number of Public Schools: ________ Elementary: ________ Secondary: _________ Total: ________

School

Physical M

I.

Public A. Elementary 1. 2.

Sub-Total (Public Elementary): B. Secondary 1. 2. Sub-Total (Public Secondary) II.

Private A. Kindergarten 1. 2.

Sub-Total (Private Kindergarten) B. Elementary 1. 2. Sub-Total (Private Elementary) C. Secondary

F

Total Number of Private Schools: ________ Elementary: _________ Secondary: __________ Total: ________ Nature of Bullying Gender Cyber Social -Based Bullying M

F

M

F

M

F

Retaliation M

F

No. of Bullying Incidents Total Total No. of No. of Total Male Female Victims Victims

Schools Division Office TONDO HIGH SCHOOL Manila 1. 2. Sub-Total (Private Secondary) Total: Note: Bullying is perpetrated by a student against another student, which may be:  Physical-unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, headlocks, etc.)  Social-refers to any deliberate, repetitive and aggressive Social behavior intended to hurt or belittle an individual (name-calling, cursing, labelling, etc.)  Gender-Based – refers to any act that humiliates or excludes 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, online games, etc.).

Prepared by:

Reviewed and Conformed by:

____________________________ Name and Designation

_______________________________ Name and Designation

____________________________ Date

_______________________________ Date

Schools Division Office TONDO HIGH SCHOOL Manila

DIVISION CONSOLIDATED REPORT ON INCIDENTS OF CHILD ABUSE SCHOOL YEAR ______________ (Based on Enclosure 2B of DepEd Memorandum No. 59, s. 2015)

Division: __________________ Total Number of Public Schools: ________ Elementary: ________ Secondary: _________ Total: ________

School

Nature of Abuse Verbal/ Physical Sexual Psychological M

I.

Public A. Elementary 1. 2.

Sub-Total (Public Elementary) B. Secondary 1. 2. Sub-Total (Public Secondary) II.

Private A. Kindergarten 1. 2.

Sub-Total (Private Kindergarten) B. Elementary 1. 2. Sub-Total (Private Elementary)

Total Number of Private Schools: ________ Elementary: _________ Secondary: __________ Total: ________

F

M

F

M

F

No. of Incidents of Child Abuse Total Total No. of Perpetrators No. of Total Male Female Incidents Victims Victims

Schools Division Office TONDO HIGH SCHOOL Manila

C. Secondary 1. 2. Sub-Total (Private Secondary) Total: Note: Child Abuse refers to the 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 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, public ridicule, threat of 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 (teachers and non-teaching staff) No amicable settlement for any acts of child abuse

Prepared by:

Reviewed and Conformed by:

_________________________________ Name and Designation

___________________________________ Name and Designation

_________________________________ Date

___________________________________ Dat

Schools Division Office TONDO HIGH SCHOOL Manila

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

Division: __________________ Total Number of Public Schools: ________ Elementary: ________ Secondary: _________ Total: ________

Name of School

School I.D.

Total Number of Private Schools: ________ Elementary: _________ Secondary: __________ Total: ________ Policy Submitted School-Based School-Based Child Child Protection Protection Policy with Policy without Anti-Bullying Anti-bullying Policy Policy

Antibullying Policy Only

I. Public A. Public 1.

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

TOTAL:

B. Secondary 1.

II. Private A. Kindergarten 1.

B. Elementary 1.

C. Secondary 1

Schools Division Office TONDO HIGH SCHOOL Manila

TOTAL:

TOTAL:

TOTAL:

Instruction: 1. * Put a check (√) on the kink pf policy the school has submitted. Choose one. 2. Get the total no. of policy submitted per category. (Ex. Total No. of School Base-Based Protection with Anti-Bullying Policy submitted by Public Elem.)

Prepared by:

______________________________ Designation

______________________________ Date

Reviewed and Conformed by:

_______________________________ Designation

_______________________________ Date

Schools Division Office TONDO HIGH SCHOOL Manila

DIVISION CONSOLIDATED REPORT ON CHILD-FRIENDLY SCHOOLS BASED ON CHECKLIST Division: _____________________ School Year: ____________________ Date of Submission: _______________________ No.

Name of School

Kindergarten/Elementary (Total Number of Schools: _______) 1. 2. 3. 4. 5. High School (Total Number of Schools: _______) 1. 2. 3. 4. 5. Sub-Total: _____ GRAND TOTAL: _____

Submitted by:

________________________________ Signature over Printed Name

________________________________ Designation

Perfect Score (37)

High Score (28-36)

Scores Below (27)