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:
