Republic of the Philippines
Province of Zamboanga del Sur
Municipality of Bayog
DIVERSION CONTRACT
For the best interest of _______________________________ and the community,
the following shall be undertaken:
For the child:
1. (Example: Clean the Barangay Park every Sunday from 8 A.M. to 10 A.M. from
January 20___ to June 20___.)
2. __________________________________________________________________
__________________________________________________________________
3. __________________________________________________________________
__________________________________________________________________
For the child’s parents:
1. (Example: Accompany the child during his/her monthly session with the social
worker to the latter’s office every first Monday of the month from January 20__
to June 20__.)
2. __________________________________________________________________
__________________________________________________________________
3. __________________________________________________________________
__________________________________________________________________
Social Worker:
1. (Example: Visit the child in his/her school once a month during the duration of
the diversion program to ascertain whether or not he/she is behaving properly
through interviews with teachers and other students.)
2. __________________________________________________________________
__________________________________________________________________
3. __________________________________________________________________
__________________________________________________________________
This contract has been signed on ______________________
____________________ _______________________ _______________________
Bata Mga Magulang Chair, Diversion Committee
Noted by: _______________________
C/MSWDO
CERTIFICATION OF FAILURE OF DIVERSION PROCEEDINGS
This is to certify that ________________________________________________ who
committed the offense ________________________________________________
[ ] does not agree to undergo a diversion program
[ ] diversion is not appropriate and applicable to the case at hand due to the
following reasons:
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
This certification is issued on __________________________________.
________________________
Chair, Diversion Committee
Noted by: _______________________________
C/MSWDO
PAGPAPATUNAY
Ito ay nagpapatunay na si _____________________________________________ na
nagkasala sa batas ng ______________________________________
[ ] hindi pumapayag na magpasailalim sa isang diversion program
[ ] ang diversion ay hindi angkop o karapat-dapat sa kaso na ito dahil sa
Sumusunod na kadahilanan:
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
Ang pagpapatunay na ito ay ibinigay ngayong ________________________.
______________________________
Namumuno ng Diversion Committee
Pinanukalaan ni: ______________________________
C/MSWDO
____________________________
City/Municipality
_________________________
Barangay
DIVERSION PROGRAM MONITORING FORM
Date:
A. Basic Information
Name of the CICL
Date of birth: Age: Sex:
School: Grade Level:
Address:
Father: Mother:
Guardian: Relationship to CICL:
B. The Case
Nature of the Offense:
Date of Contract Signing:
Agreed Day of Termination:
Results
Type/Nature of (Include CICL’s Compliance Recommendation
Intervention Activity As well as Hindering and
Facilitating Factors)
1.
2.
3.
4.
5.
6.
7.
________________________
Name and Signature of the Social Worker
CERTIFICATION OF FAILURE OF DIVERSION
This is to certify that ________________________________________________ who
committed the offense ___________________________________________________ has
failed to comply with the diversion contract to which he/she entered into with the
[ ] Katarungang Pambarangay
[ ] Law Enforcement Officer
[ ] Local Social Welfare and Development Officer
[ ] Prosecutor
due to the following reasons:
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
This certification is issued on __________________________________.
__________________________
Social Worker
PAGPAPATUNAY
Ito ay nagpapatunay na si _____________________________________________ na
nagkasala sa batas ng ______________________________________.
[ ] Katarungang Pambarangay
[ ] Law Enforcement Officer
[ ] Local Social Welfare and Development Officer
[ ] Prosecutor
dahil sa sumusunod na kadahilanan:
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
Ang pagpapatunay na ito ay ibinigay ngayong ________________________.
______________________________
LSWDO
DIVERSION PROGRAM TERMINAL REPORT
Date:
A. Basic Information
Name of the CICL
Date of birth: Age: Sex:
School: Grade/Level:
Address:
Father: Mother:
Guardian: Relationship to CICL:
Telephone/Mobile Number:
Offense Committed:
B. The Offended Party:
Name: Age: Sex:
Address:
Telephone/Mobile Number:
C. Summary of the Case/Offense:
D. Type of Diversion Program:
E. Assessment and Final Result of the Diversion Program Implementation (include
observable changes in the changes in the child’s behavior):
F. Further Recommendations:
Prepared by: ________________________
Name and Signature of the Social Worker
LGU/Region _______________________________________ Quarter/Year ______________
I. STATISTICAL REPORT. This statistical report is cumulative, meaning previous cases
will be added to the current reporting period.
A. Types of Crimes Committed by CICL
Age of CICL
# CASES Above Total
TYPES OF CRIMES 15 yrs. 16 yrs. 17 yrs.
M F M F M F M F
B. Diversion Programs for CICL
Number
by sex Status
Types of Diversion Ongoing Terminated
Program # # Not Remarks
Complied Complied
M F M F M F M F
1. Restitution of property
2. Reparation of damaged
caused
3. Indemnification for
consequential damage
4. Written/Oral Apology
5. Confiscation &
forfeiture of proceeds
and instrument
6. Care, guidance and
supervision orders
7. Counseling
8. Attendance in trainings
& seminars
a. Anger management
b. Problem solving and
conflict resolution
c. Values formation
d. Others
9. Participation in
community-based
programs & services
10. Others
Total
Under column for remarks, indicate the number of cases terminated due to non-compliance
and referred to the next level for another round of diversion proceeding/program.
C. Support Services Provided to Both the CICL and Victim
Support # of # of Funds Responsible Status
Services Benes. Services Utilized Agency (ongoing/done) Effects
Under the 4th column (Funds Utilized), monetize non-monetary services/activities like
technical assistance, venues, etc., and indicate under the 5 th column (Responsible Agency),
specific agency that provided the service/implement the activity.
