Below is a sample DepEd-style School Incident Report for bullying or physical
injury, formatted based on typical DepEd protocols (aligned with DepEd Child
Protection Policy, DO 40 s. 2012).
I can revise it to match your school, grade level, persons involved, or actual incident
details.
SAMPLE SCHOOL INCIDENT
REPORT
(Bullying / Physical Injury)
Name of School: ______________________________
School ID: ______________
District: _____________________
Division: _____________________
Region: ______________________
Date of Report: __________________
I. GENERAL INFORMATION
Type of Incident:
☐ Bullying (Physical)
☐ Bullying (Verbal)
☐ Bullying (Cyber)
☐ Physical Injury
☐ Other: __________________
Date & Time of Incident: __________________________________________
Place of Incident: ________________________________________________
Persons Involved:
Victim/Learner: ______________________________________________
Grade & Section: _____________________________________________
Alleged Offender(s): __________________________________________
Grade & Section: _____________________________________________
Witnesses (if any): ___________________________________________
Reporting Party:
☐ Teacher ☐ Adviser ☐ Prefect of Discipline
☐ Guidance Counselor ☐ Student ☐ Parent ☐ Others: ___________
II. NARRATIVE REPORT OF THE
INCIDENT
On (date and time) at approximately (time), an incident involving (victim’s name)
and (offender’s name) occurred at (specific location) within the school premises.
According to the initial accounts gathered, (briefly describe what happened). The
alleged offender (state action: pushed, punched, kicked, hit with an object,
threatened, etc.) the victim without provocation/after a verbal dispute (select
appropriate). As a result, the victim sustained (describe injury: redness, bruise,
swelling, cut, etc.).
The incident was immediately noticed by (teacher/person) who intervened and
stopped the altercation. The victim was brought to the school clinic for assessment
and first aid. The offender was escorted to the Guidance Office / Discipline Office
for initial inquiry.
III. INITIAL ACTIONS TAKEN
1.
Provided first aid to the victim.
2.
3.
Notified the class adviser(s) of both learners.
4.
5.
Called the attention of the parent/guardian of both parties.
6.
7.
Conducted initial interview with the victim, offender, and witnesses.
8.
9.
Recorded statements and secured written accounts.
10.
11.
Temporarily separated the parties involved to prevent further conflict.
12.
13.
Referred the case to the Child Protection Committee (CPC) for further
investigation in accordance with DepEd DO 40, s. 2012.
IV. RECOMMENDATIONS / FOLLOW-UP
ACTIONS
Conduct formal investigation by the CPC.
Require both parties (and parents) to attend a conference.
Provide counseling to the victim and the offender.
Implement disciplinary measures, if warranted, as per the school’s Child
Protection Policy and DepEd guidelines.
Continue monitoring the behavior and safety of both learners.
V. PREPARED BY:
Name of Reporting Teacher/Personnel: ____________________________
Position: ____________________________
Signature: ____________________________
Date: ____________________________
VI. NOTED BY:
School Head / Principal: _______________________________________
Signature: _______________________________________
Date: _______________________________________