TESDA-OP-CO-05-F26

Rev.00– 03/01/17

TECHNICALEDUCATIONANDSKILLSDEVELOPMENTAUTHORITY
PangasiwaansaEdukasyongTeknikalatPagpapaunladng Kasanayan

 APPLICATIONFORM
REFERENCENUMBER:
Qual– YY Region Province NumberSeries NumberSeries
alpha
code
AssignedtoAC PICTURE
UNIQUELEARNERSIDENTIFIER(ULI):
colored,
- - - -
passportsize,
tobefilled–outbytheProcessing Officer

Applicant’sSignature DateofApplication

NameofSchool/Training Center/Company:
Address:
TitleofAssessmentappliedfor:
 FullQualification  COC  Renewal
1.ClientType
 TVETGraduatingStudent  TVETgraduate  Industryworker  K-12  OWF
2. Profile
2.1. Name:

 SURNAME

 FIRSTNAME 
 MIDDLE

MIDDLEINITIAL
NAMEEXTENSION
(e.g.Jr.,Sr.)
NAME

Mailing
2.2.
Address:
Number,Stree t Barangay District

City Province Region ZipCode

2.3.Mother’sName 2.4.Father’sName
2.5.Sex 2.6.CivilStatus 2.7.Contact Number(s) 2.8.HighestEducational 2.9.Employment Status
Attainment
 Male  Single Tel:  ElementaryGraduate  Casual

 Female  Married Mobile:  HighSchoolGraduate  JobOrder

 Widow/er E-mail:  TVETGraduate  Probationary

 Separated Fax:  CollegeLevel  Permanent

 CollegeGraduate  Self-Employed
Others:
 Others:  OFW
2.10 Birthdate(mm/dd/yy): M M D D Y Y 2.11 Birthplace: 2.12 Age:
3. WorkExperience (NationalQualification-related)
3.2. 3.3 3.4. 3.5. 3.6
Monthly No.ofYrs.Working
NameofCompany Position InclusiveDates Statusof Appointment
. Salary Exp.

(For moreinformation,pleaseuseseparatesheet)
4.OtherTraining/SeminarsAttended(NationalQualification-related)
4.1. 4.2. 4.3. 4.4 4.5
Title Venue InclusiveDates No.ofHours ConductedBy

(For moreinformation,pleaseuseseparatesheet)

5.LicensureExamination(s)Passed
5.1. 5.2. 5.3. 5.4. 5.5. 5.6.
Title YearTaken ExaminationVenue Rating Remarks ExpiryDate

(For moreinformation,pleaseuseseparatesheet)

6.CompetencyAssessment(s)Passed
6.1. 6.2. 6.3 6.4. 6.5. 6.6.
Qualification
Title Level IndustrySector CertificateNumber Dateof Issuance ExpirationDate

(Formoreinformation,,pleaseuse separatesheet)

ADMISSIONSLIP

REFERENCENUMBER:

NameofApplicant: Tel.Number: PICTURE

AssessmentAppliedfor: OfficialReceiptNumber: Date (Passport

Issued: size)
TobeaccomplishedbytheProcessingOfficer
NameofAssessmentCenter:

Checksubmittedrequirements: Remarks:

 Accomplished Self-Assessment  Bring ownPersonalProtective Equipment

Guide

 Three(3)piecescoloredpassportsizepictures
 Others.Pls. specify

Assessment Date: AssessmentTime:

PrintedName&SignatureofProcessingOfficer PrintedName&Signatureof Applicant

Date: Date:

Note:PleasebringthisAdmissionSliponyourassessmentdate.
 TESDA-OP-QSO-02-F07
Rev.No.00-03/01/17

Reference No.
To be filled out by the Processing Officer

SELFASSESSMENTGUIDE

HEAVY EQUIPMENT OPERATION(WHEEL LOADER) NCII

Qualification:
Units of Competency  Perform pre and post-operation procedures
Covered:  Perform basic preventive maintenance servicing for earth moving
equipment
 Perform wheel loader operation
Instruction:
 Read each of the questions in the left-hand column of the chart.
 Placeacheckintheappropriateboxoppositeeachquestiontoindicateyour answer.

Can I? YES NO
 Select capacity of forklift based on job requirements 
 Travel wheel loader 
 Stock piles materials 
 Perform BLOWAF check 
 Perform load and carries materials 
 Perform visual check of equipment 
 Unload wheel loader from trailer (low or high bed) 
 Load wheel loader to trailer(low or high bed) 
 Perform post operation checks 
 Perform secondary operation 
 Prepare equipment report 
 Perform adjustment or replacement 
 Perform basic preventive maintenance servicing (PMS) 
 Perform load materials to dump truck 

Iagreetoundertakeassessmentintheknowledgethatinformationgatheredwillonlybe used for

professional development purposes and can only be accessed by concerned assessment
personnel and my manager/supervisor.

Date:
Candidate’sName&Signature

Evaluatedby:
 QualifiedforAssessment
ACManager
 NotyetQualifiedforAssessment
Date:
 TESDA-OP-CO-05-F31
Rev.No.00-03/08/17

TechnicalEducationandSkillsDevelopmentAuthority

ASSESSMENT AND CERTIFICATION PROGRAM

ATTENDANCESHEET

(TitleofQualification)

NameofCompetency Assessment
Center:
DateofAssessment:
No. CANDIDATE’SNAME ReferenceNumber: Signature AssessmentResults
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Assessor/s:
TESDARepresentative:

SignatureoverPrintedName
SignatureoverPrintedName
AccreditationNumber:

ACManager:

SignatureoverPrintedName
SignatureoverPrintedName
AccreditationNumber:
 TESDA-OP-CO-05-F28
Rev.No.01-09/02/22

TechnicalEducationandSkillsDevelopmentAuthority
ASSESSMENT AND CERTIFICATION PROGRAM

LETTEROFAPPOINTMENT

Date

DearSir/Madam:

This letter officially appoints you as competency assessor on

for (statetitleofQualification) at
(_sc_he_d_ul_e_of_a_ssess

_m_en_t)
_(n_a_m_e_an_d_a_dd_r_essof_a_ss_e_ss_m_e_nt_ce_n_te_r_. Pleasereport totheAssessment Centeras
scheduled.

Ifyouhaveanyquestions,pleasecall (_co_n_ta_ct_p_er_so_n_)_at
( p_h_o n_e_n_um_b_e_r ) .
Welookforwardtoyouracceptanceofthisappointment. Very truly

yours,

ProvincialDirector

Conforme:

Signatureof Assessor
 TESDA-OP-CO-05-F30
Rev.No.00-03/08/17

REQUESTFORMFORASSESSMENTPACKAGE/S

TITLEOF QUALIFICATION

NAMEOF ASSESSMENTCENTER

DATEOFASSESSMENT

NUMBEROFCANDIDATESFOR
ASSESSMENT

REQUESTEDBY
(POCACFocal)

DATEOFREQUEST

APPROVEDBY
(ProvincialDirector)

DATEAPPROVED
 TESDA-OP-CO-05-F29
Rev.No.00-03/08/17

LETTEROFASSIGNMENT

Date

This letter officially designates you as TESDA Representative on (Date) for (Title of
Qualification)at ( name and address of AC/AV ).
Please report to the Assessment Center/Venue as scheduled.

If you have any questions/ queries, please call the undersigned at telephone number/s
.

Verytruly yours,

ProvincialDirector

Conforme:

Signatureoverprintedname of
TESDA Representative
 TESDA-OP-CO-05-F34
Rev.No.00-03/08/17

REPORTON ASSESSMENTPROCEEDINGS
NameofCompetency Assessment
Center
AccreditationNumber
TitleofQualification
DateofAssessment No.of Candidates
NameofCompetencyAssessor
FindingsandObservations:
Items Yes No Areasfor Improvement
1.CompetencyAssessorhasasignedLetterofAppointment
2.AttendanceofthecandidatesischeckedandAdmissionSlips are verified and
collected
3.Suppliesandmaterialsareavailableduringtheconductof assessment

4.Toolsandequipmentareavailableandingoodworking conditions

5.Assessmentstartsontime
6.Conductofassessmentisinaccordancewiththemethods identified in the CATs

7.Projectsproducedbythecandidatesareinaccordancewiththe requirements in
the CATs.
8.Candidatesareprovidedwithclearandconstructivefeedback on the
assessment decision(one-on-one)
9.Assessor hastheabilitytomanagethecompetencyassessment proceedings

10.Complaintsofcandidatesareproperlyaddressedandhandled by the
Assessor& the AC, when applicable
11.AssessmentPackagesissuedtotheAssessorarecompletely returned upon
completion of assessment
12. Assessment-relateddocumentsareaccuratelyaccomplished and
submitted promptlyafterassessment
 RatingSheets
 CARS
 AttendanceSheet
 RWAC
 ApplicationFormswithSAGs
 Assessor’sGuide&SpecificInstructiontoCandidate
Narrative:(Recommendedareasforimprovementofitemswhicharenotcoveredornamed above)

Preparedby: Date:

SignatureoverPrintedName(TESDARep)
 TESDA-OP-CO-05-F35
Rev.No.00-03/08/17

LETTEROFDESIGNATION

Date

(HeadofTVI/ Company)

Dear :

This letter officially designates (NAME OF TVI/ Company) asassessmentvenue

for(TITLEOFQUALIFICATION)on (DATEOFASSESSMENT). Conductof
assessmentshallbegovernedbyProcedures ManualonCompetencyAssessment. We look

forward to your acceptance of this agreement.

Verytruly yours, Approvedby:

ACManager TESDAProvincialDirector

CONFORME:

Head,TVI/Company
 TESDA-OP-CO-05-F36
Rev.No.00-03/08/17

ASSIGNMENTOFASSESSORS
For the month of

QUALIFICATION PROVINCE
TITLE
NAMEOF ASSESSOR ASSESSMENTCENTER DATEOF
ASSESSMENT
 TESDA-OP-CO-05-F37
Rev.No.00-03/08/17
PerformanceEvaluationInstrument
Assessor’sName
Qualification
Date
Name ofRespondent
Accomplished
[Pls.Tick(🗸)whereapplicable]
 ACACManager  Candidate
INSTRUCTIONS:Putatick(🗸)markintheappropriatecolumn
5–VerySatisfactory 3–Good
SCALEGUIDE 1– Poor
4–Satisfactory 2–Fair
RATING
ITEM
5 4 3 2 1
1.Physicalappearanceandcomposure
(Pangkalahatanganyongpisikalatkungpaanomagdalasasarili)
2.Abilityto paceinstruction
(Kakayahangmagpaliwanagngmalumanayatmahusaykunganoang mga
dapat gawin)
3.Abilitytoestablishgoodrapportwith candidates
(Kakayahangmagpadaloyngkomunikasyonsapagitanniyaatngmga
kukuha ng pagsusulit)
4.Abilitytoensurethatthecandidateunderstandstheinstruction
(Kakayahangsiguraduhinganglahatnginstruksyonaynaiintindihan ng
mga kukuha ng pagsusulit)
5.Abilityto answerquerries,comments, etc.
(Kakayahangmagbigayng karapatdapatnasagototugonsamga tanong,
puna o mga paglilinaw)
6.Abilitytoestablishtheassessmentcontextandpurposeof assessment
(Kakayahangmagpaliwanagtungkolsalayuninngpagsusulit)

7.Abilitytoplanandpreparetheevidencegathering process
(Kakayahangpaghandaanatiayosangmgapangangailangansa pagsusulit)

8.Abilitytoprovideallowable/reasonableadjustmentsinthe assessment
procedure
(Kakayahangmagbigayngmakabuluhangkonsiderasyonsamay Mga
pangangailangan sa pagsusulit)
9.Abilitytoconductassessmentinaccordancewiththe methodologies
(Kakayahangipatupadangpagsusulitayonsamgaitinakdang panuntunan)

10.Abilitytocollectappropriateevidenceduring theconductof assessment

(Kakayahangmangalapatsumuringmgatamangebidensya habang
nagbibigayng pagsusulit

11.Abilitytoprovideclearandconstructivefeedbackonthe assessment decision

(Kakayahangmagbigayngmalinawattamangkaukulangopinyon
 saresultang pagsusulit)

12.Abilitytoprovidefair,reliableandvalidassessmentdecision
(Kakayahangmagbigayngpantay,ugmaattamangdesisyonsa resulta ng
pagsusulit)
Sub- score
FINALRATING
Signature ofRespondent

FORTESDAUSEONLY

EVALUATOR’SREMARKS:

RECOMMENDATION:
 YES
Forre-accreditation
 NO
 Forfurtherreview

*Frequency
ForACManager– oncea month
ForCandidate-at least2candidatesperassessment schedule
 TESDA-OP-CO-05-F38
Rev.No.00-03/08/17

UTILIZATIONREPORTONBLANKCERTIFICATESISSUED
REGION

InclusiveSerial No. Recipient InclusiveSerial No. Spoilage

Quantity Date Quantity Available
NameofForm Received Received
(Province/ Serial
From To
District) Issued From To Qty
No. Balance

Preparedby: Signature: Date:

CertifiedCorrect:(RegionalDirector) Signature: Date
 TESDA-OP-CO-05-F42
Rev.No.00-03/08/17
TRACKING
SHEETPREPARATIONANDISSUANCEOFCERTIFIC
ATE
For the month of
TITLE OF DATE OF DATE OF DATE OF SIGNATUREOF DATEOFRECEIPTOF
QUALIFICATION ASSESSMENT RECEIPT OF PRINTING CANDIDATE NC/ COC BY THE
NAME CARSBYTHE OFNC/COC CANDIDATE
PO
LASTNAME FIRSTNAME MI

Preparedby: Notedby:

Name& Signature ProvincialDirector

 TESDA-OP-CO-05-F27
Rev.No.00-03/08/17

LETTEROFAUTHORIZATION

I, , of legal age, Filipino, single/married with

address at , do hereby name, constitute
and appoint oflegalage,Filipino,single/married and
with address at ,tobemytrueand
lawfulattorney,formeandinmyname,placeandstead,toperformthefollowingacts and things, to
wit:

1. To claim my Certificate in ;and

2. Tosignalldocumentsnecessaryfortheconductofsaidtransaction.

Issued on ,20 at .

SignatureoftheCertifiedWorker

Authorized Representative
(SignatureoverPrintedName)

ForTESDAuseonly

Iherebyattestthat theclaimantpresentedthefollowing:

□ OriginalcopyofCARS
□ PhotocopyofIDofthecertified worker
□ AccreditationIDofclaimant(ifLiaisonOfficer)
□ PhotocopyIDofclaimant

TESDA PO CAC Focal person

(SignatureoverPrintedName)