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Annex "A"

Report of cases of abuse, violence, exploitation, discrimination, bullying or peer abuse and other
related offenses

School/Division/Region : _____________________________________
Period Covered : _____________________________________
Person Submitting Report: ____________________________________ Designation: ______________________ Date: __________________

VICTIM/S RESPONDENT/S
SEX SEX NATURE OF ACTION/S
NAME AGE (M or F) NAME AGE (M or F) COMPLAINT TAKEN RECOMMENDATION/S

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