Republic of the Philippines

Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

INFORMATION ABOUT THE APPLICANT

Name of Applicant/Proponent First Name Middle Initial Surname

Position Agency/Functional
Position – Office/School
Division

A. PROFILE OF THE ACTIVITY

Title of the Activity IN ALL CAPS

Activity Request Number/

Authority to Conduct Number

LDIS Tracking Number

Legal and other logical bases (e.g. LDNA) for the conduct of this program. (Indented)
Rationale

Program or Course Description Key content (Indented)

Professional Standards Covered e.g. PPST, PPSSH, or PPSS domain/s, strands, indicator/s

Target Participant Profile e.g. Career Stage, Grade Level, Learning area

** hours of face-to-face instruction and/or online learning, and classroom application (if
Number of Hours
applicable)

List of Resource Persons/ First Name Middle Initial Surname, Position – Office/School

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

Learning Facilitators (attach Curriculum Vitae)

e.g. Formal Learning, possibly with Job-Embedded Learning (JEL), Learning Action Cell (LAC),
Modality
relationship and discussion-based learning, among other modalities

Delivery Platform e.g. Online, face-to-face and blended delivery

Indicative Date of
Month 1 - 30, 2021
Implementation

Professional Regulation
Commission (PRC) Program If applicable
Accreditation No

B. PROGRAM COURSE DESIGN

c.1 Objective/s & Outcome/s or Output/s

At the end of this activity, the women and men participants will be able to
Terminal Objective

Specifically, it aims to:

1. For KNOWLEDGE
Enabling Objectives
2. For SKILLS
3. For ATTITUDES
Expected Tangible Outputs At the end of this activity, the participants, inclusive of both male and female, are

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

expected to:
1.
2. ; and
3.
At the end of this activity, the participants, inclusive of both male and female, are
expected to:

Expected Intangible Outcomes 1.

2. ; and
3.

c.2 Detailed Program Matrix

Day 1 – Month 00, 2021

Date/Time Topic/Activity Responsible Person/s

7:45–8:00 Registration FIRST NAME MIDDLE INITIAL SURNAME

a.m.
Position
(15 mins.)

8:00–8:30 Preliminaries FIRST NAME MIDDLE INITIAL SURNAME

a.m.

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

- Prayer Position
- Nationalistic Song/Philippine National Anthem
- Opening Remarks
(30 mins.) - Inspirational Message
- Statement of Purpose
- House Rules
- Acknowledgement of Participants

8:30–12:0 Program Proper FIRST NAME MIDDLE INITIAL SURNAME

n.n.
Position
(1 hour, 30
mins.)

12:00–1:00 LUNCH BREAK

p.m.
(1 hour)

1:00–4:30 Program Proper FIRST NAME MIDDLE INITIAL SURNAME

p.m.
Position
(1 hour, 30
mins.)

4:30–5:00 Closing Program FIRST NAME MIDDLE INITIAL SURNAME

p.m.
Position

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

(30 mins)

c.3 Requirements or Resource Package/s

Modules or Learning
slide deck and/or audio-visual presentations, Google Drive links may be included
Resources to be used
Requirements e.g. customized t-shirt, campaign collaterals, sound system
Documents e.g. activity design, attendance sheets, certificates, and other tools

c.4. Assessment Plan

C. ACTIVITY IMPLEMENTATION PLAN

d.1. Schedule of Activities (Refer to specific course objectives and/or instructional design)
d.2. Budgetary Requirements and Funding Source (see attachments)
d.3. Monitoring and Evaluation (see attached M&E tool)
This proposal must be reviewed by HRD section to verify its compliance on the Learning and Development (L&D) System standards
before the PDC Chairperson’s review and evaluation. The entire process of the training will be observed, monitored, and evaluated by
Division QATAME Associate with corresponding online evaluation tool.

d.4. Gender and Development Mainstreaming (see attached HGDG Education Checklist Rating tool)
The program management team ensures that gender perspectives and needs are always considered in the design, implementation,
monitoring and evaluation of the training. Likewise, it seeks to ensure that participants (regardless of gender preference) have equitable

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

access to and benefit from society’s resources and opportunities. Its HGDG rating must be verified by SEPS-M&E Voltaire C. Asildo
using the prescribed tool to ensure compliance to GAD perspectives and mandates for gender mainstreaming, regardless of the activity
being included in the GAD Plan or not.
CHARGEABLE AGAINST: 2021 INSET FUNDS
☐included in the GAD Plan 2021 with 100 % Appropriation - ₱ 000,000.00
☐excluded in the GAD Plan 2021 with 00 % Attribution - ₱ 000,000.00

d.5 Minimum Health Standards (MHS)

MHS set by the DepEd Inter-Agency Task Force must be followed. Social distancing and regular sanitary guidelines must be
observed. An on-site medical staff shall be assigned to monitor the whole duration of the activity.

E. OTHER ATTACHMENTS
e.1. List of Menu (see attachments)
e.2. Purchase Request (see attachments)
e.3. Program Management Team with Terms of Reference (see attachments)
e.4. List of Participants (see attachments)
e.5. Division Memorandum (see attachments)
(NOTE: all mentioned documents as see attachments must be attached during the evaluation for approval to avoid delay. Kindly delete this note
before submission.)

(NOTE: Use this for NEAP recognition and CPD accreditation application. Kindly change the name of the Finance Section Head if the budget is not
from the division. The Funds Available must be deleted if no expense is incurred. Kindly delete this note before submission.)

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

Prepared by: Noted by:

PROPONENT’S NAME IMMEDIATE SUPERIOR

Proponent’s Position Immediate Superior’s Position

Reviewed and Evaluated by: Funds Available:

GILBERT L. GAYRAMA, CESE BETHANY E. CLIMACO

PDC Chairperson/Chief EPS, Accountant III/Finance Section Head
OIC-Office of the Assistant Schools Division Superintendent

Recommended for Approval:

JOSITA B. CARMEN, CESO V

Schools Division Superintendent

Approved:

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

MA. GEMMA M. LEDESMA, CESO V

Director IV

(NOTE: Use this for L&D proposal design application at the division level only. Kindly change the name of the Finance Section Head if the budget
is not from the division. The Funds Available must be deleted if no expense is incurred. Kindly delete this note before submission.)
Prepared by: Noted by :

PROPONENT’S NAME IMMEDIATE SUPERIOR

Proponent’s Position Immediate Superior’s Position

Reviewed and Recommended for Approval: Funds Available:

GILBERT L. GAYRAMA, CESE BETHANY E. CLIMACO

PDC Chairperson/Chief EPS, Accountant III/Finance Section Head
OIC-Office of the Assistant Schools Division Superintendent

Approved:

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR

JOSITA B. CARMEN, CESO V

Schools Division Superintendent

Balilahan, Mabua, Tandag City, Surigao del Sur, 8300

(086) 211-3225
[email protected]
ISO Cert. No.
AW/PH909100102
Date: 04-22-2021Version: V3DC No: F-SGOD-HRD-25