SCHOOLS DIVISION OF TARLAC PROVINCE

NAME OF YOUR SCHOOL HERE

Address of Your School Here

CERTIFICATE OF ACCEPTANCE

This classroom-based action research proposal entitled “TYPE THE TITLE OF

YOUR ACTION RESEARCH HERE”, prepared and submitted by YOUR NAME
HERE, was evaluated by the Committee and recommended for acceptance.

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SCHOOLS DIVISION RESEARCH COMMITTEE

NAME OF THE ASDS IN CHARGE IN YOUR AREA

Assistant Schools Division Superintendent
Chairman

PAULINO D. DE PANO, Ph.D. NOEL L. LINSAO, Ed.D.

Chief Education Supervisor Chief Education Supervisor
Curriculum and Implementation Division School Governance and Operations Division
Member Member

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Accepted on ________________________.

RONALDO A. POZON, Ph.D., CESO V

Schools Division Superintendent
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Type You Research Title Here

Write the names of group members here separated by comma

Name of Your School, Address of Your School

Month Year
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TABLE OF CONTENTS

Page

Title Page ………………………… 1

Table of Contents ………………………… 2

Context and Rationale ………………………… 4

Research Questions ………………………… 7

Hypothesis ………………………… 11

Significance of the Study ………………………… 8

Scope and Limitations ………………………… 9

Method ………………………… 9

Type of Research ………………………… 10

Respondents ………………………… 10

Sampling Method ………………………… 10

Proposed Innovation/Intervention/Strategy ………………………… 11

Instruments ………………………… 11

Data Collection Procedure ………………………… 11

Ethical Considerations ………………………… 13

Data Analysis ………………………… 14

Work Plan ………………………… 11

Cost Estimates ………………………… 13

Plans for Dissemination and Utilization ………………………… 14

References ……………… 17

Appendices
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A. Instruments ……………… 19

B. Questionnaire on Establishing the Content-Validity ……………… 24

of the Instruments

C. Consent and Assent Letters ……………… 25

D. Declaration of Anti-Plagiarism ……………… 25

C. Declaration of Absence of Conflict of Interest ……………… 25

CONTEXT AND RATIONALE

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Type here the background of study or the rationale. This should be at least 1 page

and at most 6 pages.

Research Questions

Generally, this research …

Specifically, it aims to answer the following research questions:

1. Type here question 1

2. Type here question 2

3. Type here question 3

4. Type here question 4

5. Type here question 5

You must have at least 3 questions and at most 6.

Hypothesis

In connection to research question no. ____ and no. ____, the following research

hypotheses shall be tested at 0.05 alpha level of significance.

1. Type here your research hypothesis

2. Type here your research hypothesis

Significance of the Study

Type here the Significance of Study. First you must have 1 to 2 paragraphs stating

the overall significance of the study then list the beneficiaries with the specific benefits

they will get.

Beneficiary 1. Type here the benefit the beneficiary will get…

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Beneficiary 2. Type here the benefit the beneficiary will get…

Beneficiary 3. Type here the benefit the beneficiary will get…

Scope and Limitations

Type here Type here Type here Type here Type here Type here Type here Type

here Type here Type here Type here Type here Type here Type here Type here Type here

Type here Type here Type here Type here Type here Type here Type here.

METHOD

This section discusses the methods and statistics to be used in this study. It

includes the type of research, respondents, sampling method, proposed innovation/

intervention/ strategy, instruments, data collection procedures, ethical considerations,

data analysis, work plan, cost estimates, and plans for dissemination and utilization.

Type of Research

Type here… Identify the type of your research and at the same time cite an author

explaining the type of research identified.

Respondents

Who are your respondents? Type here…

Sampling Method

What sampling method did you use? Type here…

Instrument/s
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What is your proposed innovation/intervention/strategy? Describe/explain it…

Instrument/s

What is your instrument in gathering data? Describe it by parts. Type here…

Data Collection Procedure

What are the steps you will take in gathering the data? Type here.

Ethical Considerations

What are the ethical considerations in your research that your group will take?

Type here…

Data Analysis

How will you analyze the data gathered? What are the specific statistics you will

employ? Remember to start the discussion according to the arrangement of the research

questions. Type here…

Work Plan

Make a matrix of your workplan… An Example is given below…

Phase Time Activity Persons Expected

Frame Involved Output/
Outcome
Pre-
Implementation
Implementation
Post-
Implementation

Cost Estimates
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Show the financial statement in conducting your research

Phase Particulars Amount

Pre-Implementation
Implementation
Post-Implementation
Total

Plans for Dissemination and Utilization

State your plans to disseminate and utilize the results of your research.

REFERENCES
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Calderon, J.P. (2016). Ang pagbagsak ng mga mag-aaral ng research dahil sa

katamaran. San Felipe High School Publication.

Type here Type here Type here Type here Type here Type here Type here Type here
Type here Type here

Type here Type here Type here Type here Type here Type here Type here Type here
Type here Type here

Type here Type here Type here Type here Type here Type here Type here Type here
Type here Type here

APPENDIX A
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QUESTIONNAIRE-CHECKLIST ON ____

APPENDIX B
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QUESTIONNAIRE ON ESTABLISHING THE CONTENT-VALIDITY

OF ________ (Adopted from Calderon, 2021)

Name: ________________________________________________________________________
Designation: ___________________________________________________________________
Station/Department: _____________________________________________________________

Direction: Enclosed is a Questionnaire-Checklist on _______________________. Using the

rating table below, please evaluate carefully by putting a check ( ✔) mark on the blank
corresponding to the degree of your agreement on each item.

Numerical
Descriptive Rating Description
Rating
5 Strongly Agree When the evaluator found out no flaw with the questionnaire-checklist.
(SA)
4 Agree When the evaluator found out very little flaws with the questionnaire-
(A) checklist.
3 Moderately Agree When the evaluator found out some flaws with the questionnaire-
(MA) checklist.
2 Disagree When the evaluator found out several flaws with the questionnaire-
(D) checklist.
1 Strongly Disagree When the evaluator suggests major revision is needed with the
(SD) questionnaire-checklist.

5 4 3 2 1
Indicators
SA A MA D SD
1 The directions given are simple.
2 The directions are comprehensible.
3 The layout is well-organized.
4 The items are stated well-defined.
5 The items are stated briefly.
6 The items are legible.
7 The items are not duplicated.
8 The items are stated systematically.
9 The items are inclined with the objectives of the study.
10 The items are representative of the behavior/s measured.

Comments/Suggestions/Recommendations:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

APPENDIX C
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LETTER OF CONSENT/ASSENT

APPENDIX D
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DECLARATION OF ANTI-PLAGIARISM
(Annex 3 of DO No. 16, s. 2017)

1. I, __________________________________, understand that plagiarism is the act

of taking and using another’s ideas and works and passing them off as one’s own.
This includes explicitly copying the whole work of another person and/or using
some parts of their work without proper acknowledgment and referencing.

2. I hereby attest to the originality of this research proposal and has cited properly all
the references used. I further commit tht all deliverables and the final research
study emanating from this proposal shall be of original content. I shall use
appropriate citations in referencing other works from various sources.

3. I understand that violation from this declaration and commitment shall be subject
to consequences and shall be dealt with accordingly by the Department of
Education and (insert grant mechanism).

Proponent: ________________________________
Signature:_________________________________
Date:_____________________________________

Proponent: ________________________________
Signature:_________________________________
Date:_____________________________________

Proponent: ________________________________
Signature:_________________________________
Date:_____________________________________

APPENDIX E
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DECLARATION OF ABSENCE OF CONFLICT OF INTEREST

(Annex 3 of DO No. 16, s. 2017)

1. I, __________________________________, understand that conflict of interest

refers to situations in which financial or other personal considerations may
compromise my judgment in evaluating, conducting, or reporting research.

2. I hereby declare that I do not have any personal conflict of interest that may arise
from my application and submission of my research proposal. I understand that
my research proposal may be returned to me if found out that there is conflict of
interest during the initial screening as per DO No. 16, s. 2017.

3. Further, in case of any form of conflict of interest (possible or actual) which may
inadvertently emerge during the conduct of my research, I will duly report it to
the research committee for immediate action.

4. I understand that I may be held accountable by the Department of Education and

(insert grant mechanism) for any conflict of interest which I have intentionally
concealed.

Proponent: ________________________________
Signature:_________________________________
Date:_____________________________________

Proponent: ________________________________
Signature:_________________________________
Date:_____________________________________

Proponent: ________________________________
Signature:_________________________________
Date:_____________________________________