COMMON TEMPLATE

TEACHER-INITIATIVE IN THE DEVELOPMENT OF STORY BOOKS/ STRATEGIC INTERVENTION

MATERIAL (SIM)/ACTIVITY SHEETS (AS)/SELF-LEARNING MODULES (SLM)
AND OTHER PRINTED LEARNING MATERIALS

OUTLINE

General Components:

A. Cover Page
B. Title Page
C. Copyright Page
D. Table of Contents
E. Background Information
F. Components of the Initiative:
1. Learning Area, Grade level, Quarter Period
2. Title of the Initiative
3. Most Essential Learning Competency/ies (MELCs)
4. Directions/Instructions
5. The Activities
6. Rubrics for Scoring (if applicable)
7. Answer key for the Activities

Note:
1. For the Proposal Stage, the developer should discuss briefly the Background
Information and 1 to 5 of the Components of the Initiative.

2. For the Final Stage, the writer should have completed all the parts that are stated
in the General Components.
PROPOSAL STAGE

INDORSEMENT
(P.1)
___________________________
School Heading

1st Indorsement
________________
(Date)

Respectfully forwarded to the Schools Division Superintendent, Division of La Union, City

of San Fernando, La Union the herein request of (Writer’s Name/Position) of (School/School
Address) to proceed with an initiative to develop (Type of initiative), for approval.

______________________________
Name and Signature of School Head
Position

REQUEST LETTER
(p.2)
________________________
School Heading
______________
Date
ATTY. DONATO D. BALDERAS, JR.
Schools Division Superintendent
DepEd-Divison of La Union

S I R:
I have the honor to request permission from your good office to develop (type of
Initiative) for Grade ___ learners to be used in our ____________ (school or district or
division).

Your approval to this request is highly appreciated.

Very truly yours,

Writer’s Name/Signature
Position
APPROVAL SHEET
__________________
Division Heading

APPROVAL SHEET

This ________(type of initiative)_____________, proposed by (Name of

Teacher/Position) of (School/School Address) was examined by the Division Evaluation
Committee on (Date).

Initial pertinent documents submitted/attached have been read, thoroughly evaluated

and validated by the Division Evaluation Committee and thereby recommended for approval of
the Schools Division Superintendent.

DIVISION EVALUATION COMMITTEE:

__________________________________
(EPS In-Charge of the Learning Area)

DR. VIRGILIO C. BOADO

EPS - Learning Resource Management

DR. GERMAN E. FLORA

Chief Education Program Supervisor
Curriculum Implementation Division

APPROVED:

ATTY. DONATO D. BALDERAS, JR.

Schools Division Superintendent

FOR THE SCHOOLS DIVISION SUPERINTENDENT:

VIVIAN LUZ S. PAGATPATAN, PhD, CESO VI

Assistant Schools Division Superintendent
FINAL STAGE

INDORSEMENT
(p.1)
_______________________
School Heading

2nd Indorsement
________________
(Date)

Respectfully forwarded to the Schools Division Superintendent, Division of La Union, City

of San Fernando, La Union the herein (Type of initiative) developed by (Writer’s
Name/Position) of (School/School Address), for approval.

______________________________
Name and Signature of School Head
Position

REQUEST LETTER
(p.2)
________________________
School Heading

______________
Date
ATTY. DONATO D. BALDERAS, JR.
Schools Division Superintendent
DepEd-Divison of La Union

S I R:

I have the honor to submit to your good office the developed (type of Initiative) for
Grade ___ learners to be used in our ____________ (school or district or division).

Your approval to this output is highly appreciated.

Very truly yours,

Writer’s Name/Signature
Position
APPROVAL SHEET

_____________________
Division Heading

APPROVAL SHEET

This ________(type of initiative)_____________, prepared and submitted by (Name

of Teacher/Position) of (School/School Address) was examined by the Division Evaluation
Committee on (Date).

Pertinent documents submitted/attached have been read and thoroughly evaluated and
validated using the Evaluation Tool Standard prescribed by the DepEd-BLR by the Division
Evaluation Committee and thereby recommended for approval of the Schools Division
Superintendent.

DIVISION EVALUATION COMMITTEE:

__________________________________
(EPS In-Charge of the Learning Area)

DR. VIRGILIO C. BOADO

EPS - Learning Resource Management

DR. GERMAN E. FLORA

Chief Education Program Supervisor
Curriculum Implementation Division

APPROVED:

ATTY. DONATO D. BALDERAS, JR.

Schools Division Superintendent

FOR THE SCHOOLS DIVISION SUPERINTENDENT:

VIVIAN LUZ S. PAGATPATAN, PhD, CESO VI

Assistant Schools Division Superintendent
Attachment No. 1 Recent 2x2 Picture

CURRICULUM VITAE

NAME:
School:
Position:
School Address:
Contact Number:
DepEd Email Address:

Personal Background

Permanent Residence:
Birthdate:
Birthplace:
Father’s Name:
Mother’s Name:
Spouse Name (if married):

Educational Attainment

Graduate Study: School: Address:

Tertiary: School: Address:
Secondary: School: Address:
Elementary: School: Address:

Government Eligibility/ies:
_____________________________

_____________________________

Teaching-related Work Experience:

Position: School: Year: