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
Complete Office Address
Contact Person Mobile No.
Telephone No. Email Address
NEAP Authorization Number

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.

Title
1

Rationale
2

Program Description
3

4
Professional Development
Priorities

PRC
6

Program
Target Participant
5
Accreditation
No.

8
Indicative Date of
Delivery Platform
7
Implementation

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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.
Course
9 10
Title Professional Standards Covered
11
Schedule
12 13
Modality

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

Course
15

Description
Resource
22

16
Duratio Assessment
20
Person/
Topic
17 18
Session Objectives Methodology
19 21
Outputs
n Strategies Learning
Facilitator

Add more rows to add sessions.

PROGRAM IMPLEMENTATION PLAN

23
Funding Budget
24

Source Requiremen

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 ts

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 Data Schedule of Person/s User of M and

Indicators Resources
E and Tools Sources M and E Responsible E Data
25
Results

26
Behavior

27
Learning

28
Reaction

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.

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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
Signature
Date 11/09/2021
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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