Republic of the Philippines Effectivity Date: September 20, 2021

Department of Education Version No. 1

DepEd Complex, Meralco Avenue Revision No.: 00
Pasig City 1600 Page No.: 1 of 6

Professional Development Program/Course Recognition Application Form Reference No.: CO-NEAP-F018

INSTRUCTIONS: Input the necessary details. Indicate N/A if not applicable. DO NOT ABBREVIATE.

LEARNING SERVICE PROVIDER PROFILE

Learning Service Provider Type the complete name.
Complete Office Address Type the complete office address.
Contact Person Type the complete name. Mobile No. Type the mobile no.
Telephone No. Type the office telephone no. Email Address Type Email address.
NEAP Authorization Number For Authorized Learning Service Provider only.

Address: 2/F Mabini Building, DepEd Complex, Meralco Avenue, Pasig City 1600
Telephone No.: (02) 8638-8638 / (02) 8633-7207 / (02) 8635-4796
Email Address: [email protected] / [email protected]
 Republic of the Philippines Effectivity Date: September 20, 2021
Department of Education Version No. 1
DepEd Complex, Meralco Avenue Revision No.: 00
Pasig City 1600 Page No.: 2 of 6

Professional Development Program/Course Recognition Application Form Reference No.: CO-NEAP-F017

PROGRAM PROFILE
You will need to complete the following components to describe the program you would like to be recognized.
1
Title Type the Program Title here.
300-350 minimum words
2
Rationale (Outline the reasons for offering this program. You should consider the need this program addresses for
teachers and include an overview of how relevant and reliable research relates to the content and/or delivery
of the program. Include citations in your overview. Also, provide references to the sources outlined.)
100-150 minimum words
(Provide a brief description of the program. State the Terminal Objective/s and Enabling Objective/s of the
program by referring to what participants will gain in terms of their professional knowledge, professional
practice and/or professional engagement. Objectives should follow the SMART principle.)

Terminal Objective is defined as what the participants will achieve upon successful completion of a
program or course.
3
Program Description
STEM STATEMENT/S:

By the end of this Program, participants will be able to:

Enabling Objectives are the specific objectives that support the Terminal Objective/s.
4
Professional Development (State the DepEd Professional Development Priorities this program covered or DM 50 s. 2020 and/or other emerging
Priorities needs of the Department.)
5 6
Target Participant (Please specify your participants based on their career stage, subject area, PRC (For Non-DepEd LSPs)
grade level, etc.) Program
Accreditation

Address: 2/F Mabini Building, DepEd Complex, Meralco Avenue, Pasig City 1600
Telephone No.: (02) 8638-8638 / (02) 8633-7207 / (02) 8635-4796
Email Address: [email protected] / [email protected]
 Republic of the Philippines Effectivity Date: September 20, 2021
Department of Education Version No. 1
DepEd Complex, Meralco Avenue Revision No.: 00
Pasig City 1600 Page No.: 3 of 6

Professional Development Program/Course Recognition Application Form Reference No.: CO-NEAP-F017

No.
8
7 Identify delivery platform here. Indicative Date of From Start Date to End Date
Delivery Platform
Implementation

COURSE LIST
Learning Service Providers can attach one or more courses in a program for recognition. You are required to list courses you are applying
for recognition in the table below and then provide a detailed description of each course on the COURSE DESIGN page.
9 10 11 12 13
Course Title Professional Standards Covered Schedule Modality
1 Type here. (PPST, PPSSH, PPSS with specific domain/s and strand/s, From Start Date to Choose an item.
indicator/s) End Date
2 Type here. (PPST, PPSSH, PPSS with specific domain/s and strand/s, From Start Date to Choose an item.
indicator/s) End Date
3 Type here. (PPST, PPSSH, PPSS with specific domain/s and strand/s, From Start Date to Choose an item.
indicator/s) End Date
4 Type here. (PPST, PPSSH, PPSS with specific domain/s and strand/s, From Start Date to Choose an item.
indicator/s) End Date
5 Type here. (PPST, PPSSH, PPSS with specific domain/s and strand/s, From Start Date to Choose an item.
indicator/s) End Date
Add more row to add courses.

COURSE DESIGN
Provide a detailed description of each of the course by breaking it into discrete sessions. You may create a copy of this page if you have two
or more courses.

Address: 2/F Mabini Building, DepEd Complex, Meralco Avenue, Pasig City 1600
Telephone No.: (02) 8638-8638 / (02) 8633-7207 / (02) 8635-4796
Email Address: [email protected] / [email protected]
 Republic of the Philippines Effectivity Date: September 20, 2021
Department of Education Version No. 1
DepEd Complex, Meralco Avenue Revision No.: 00
Pasig City 1600 Page No.: 4 of 6

Professional Development Program/Course Recognition Application Form Reference No.: CO-NEAP-F017

14
Course Title
15
Course Description
22
18 20 Resource
16 17 Session 19 Assessment 21
Duration Topic Methodology Outputs Person/ Learning
Objectives Strategies
Facilitator
Explain, in detail, the professional Identify the
Describe its
development activities including Resource Person/
topic (focus, Explain how
the learning resources that Describe what Learning
content and the learning
teachers/school leaders will teachers/schoo Facilitator
key learning outcomes will
State its Describe its engage in, clearly describing how l leaders’ responsible for
points or what be assessed;
duration, session the presenter will facilitate each outputs to this session. Use
1 teachers will be if possible
e.g. 90 objectives. (30- session and how the participants achieve attached CV
learning about). attach an
minutes 50 words) will engage with the content and learning Template as
(May be a assessment
meet the domain/s, strand/s and outcomes. (50- reference.
listing of main tool. (50-75
indicator/s in the selected 75 words)
topics or key words)
Professional Standards. (100-150
messages)
words)
Type Type here. Type here. Type here. Type here. Type here. Type here.
2
here.
Type Type here. Type here. Type here. Type here. Type here. Type here.
3
here.
Type Type here. Type here. Type here. Type here. Type here. Type here.
4
here.
Type Type here. Type here. Type here. Type here. Type here. Type here.
5
here.

Add more row to add sessions.

Address: 2/F Mabini Building, DepEd Complex, Meralco Avenue, Pasig City 1600
Telephone No.: (02) 8638-8638 / (02) 8633-7207 / (02) 8635-4796
Email Address: [email protected] / [email protected]
 Republic of the Philippines Effectivity Date: September 20, 2021
Department of Education Version No. 1
DepEd Complex, Meralco Avenue Revision No.: 00
Pasig City 1600 Page No.: 5 of 6

Professional Development Program/Course Recognition Application Form Reference No.: CO-NEAP-F017

PROGRAM/COURSE IMPLEMENTATION PLAN

23 How the program will be 24

Budget Provide details on how the funds will be allocated. If registration, how much
Funding Source
funded? Requirements will be collected in each course?

Monitoring and Evaluation Plan

This is a sample M and E Plan following the Kirkpatrick Evaluation Model, if you have an existing M and E Plan you may use that instead.

Methods and Schedule of M User of M and E

Level of M and E Indicators Data Sources Person/s Responsible Support Needed
Tools and E Data
25
Results What will be What Who and/or what When will M and Who will be accountable What resources Who will use the data
measured? methods/tools documents will E activities be for ensuring that M and E are needed to gathered?
will be used to provide data or undertaken? activities are done? implement M and
collect data? evidence on the E activities?
indicators?
26
Behavior Type here. Type here. Type here. Type here. Type here. Type here. Type here.
27
Learning Type here. Type here. Type here. Type here. Type here. Type here. Type here.
28
Reaction Type here. Type here. Type here. Type here. Type here. Type here. Type here.

Address: 2/F Mabini Building, DepEd Complex, Meralco Avenue, Pasig City 1600
Telephone No.: (02) 8638-8638 / (02) 8633-7207 / (02) 8635-4796
Email Address: [email protected] / [email protected]
 Republic of the Philippines Effectivity Date: September 20, 2021
Department of Education Version No. 1
DepEd Complex, Meralco Avenue Revision No.: 00
Pasig City 1600 Page No.: 6 of 6

Professional Development Program/Course Recognition Application Form Reference No.: CO-NEAP-F017

Declaration:

I hereby declare the information provided in this application is true and correct and there have been no misleading statements,
omission of any relevant facts nor any misinterpretation made.

Sign off by the Program/Course Manager or its equivalent

Program Manager Type here
Signature
Date Click here to enter a date.
This Form is not valid if not signed.

Required Attached Documents:

Detailed Course Design
Sample Learning Resources (Modules, Worksheets, etc.)
Sample Session Guides
Sample Assessment Tools
CVs of Primary, Secondary, or Alternate Resource
Persons
Budget Estimate Form
Monitoring and Evaluation Plan

Address: 2/F Mabini Building, DepEd Complex, Meralco Avenue, Pasig City 1600
Telephone No.: (02) 8638-8638 / (02) 8633-7207 / (02) 8635-4796
Email Address: [email protected] / [email protected]