Republic of the Philippines

Department of Education

National Educators Academy of the Philippines

FORM R.1 Professional Development Program/Course Recognition Application Form

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.

Version April 2021 Page 1

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 (Outline the reasons for offering this program. You should consider the need this program addresses for
Rationale
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
Priorities
6
(Please specify your participants based on their career stage, subject PRC Program (For Non-DepEd
5
Target Participant area, grade level, etc.) Accreditation LSPs)
No.
7
Delivery Platform Identify delivery platform here. 8
Indicative Date of Implementation From Start Date to End Date

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.

Professional Development Programs/Courses Recognition Application Form Page 2

 9 10 11 12 13
Course Title Professional Standards Covered Schedule Modality
1 Type here. (PPST, PPSSH, PPSS with specific domain/s and From Start Date to Choose an item.
strand/s, indicator/s) End Date
2 Type here. (PPST, PPSSH, PPSS with specific domain/s and From Start Date to Choose an item.
strand/s, indicator/s) End Date
3 Type here. (PPST, PPSSH, PPSS with specific domain/s and From Start Date to Choose an item.
strand/s, indicator/s) End Date
4 Type here. (PPST, PPSSH, PPSS with specific domain/s and From Start Date to Choose an item.
strand/s, indicator/s) End Date
5 Type here. (PPST, PPSSH, PPSS with specific domain/s and From Start Date to Choose an item.
strand/s, indicator/s) End Date
Add more rows to add courses.

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

Add more rows to add sessions.

PROGRAM IMPLEMENTATION PLAN

23 24
Funding Source Budget Provide details
Requirements on how the
How will funds will be
the allocated. If
program be registration,
funded? how much will

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 be collected in
each course?
Use attached
budget
estimate
template as
reference.

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.

Levels of M and Methods and Schedule of M User of M and E

Indicators Data Sources Person/s Responsible Resources
E Tools and E Data
25
Results What will What Who and/or When will M Who will be What resources Who will use the
be methods/tool what and E accountable for are needed to data gathered?
measured? s will be used documents activities be ensuring that M and E implement M
to collect will provide undertaken? activities are done? and E
data? data or activities?
evidence on
the
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.

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.

Professional Development Programs/Courses Recognition Application Form Page 5

I agree that the DepEd-National Educators Academy of the Philippines to be the co-owner of all the data gathered and the
copyright of any publication of the use of these data.

Sign off by the Program/Course Manager or its equivalent

Program Manager Type here
Signature
Date Click here to enter a date.
This Form R.1 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

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