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Proposal Form For Extension Services

This document is an extension activity proposal form for a college. It requests information such as the extension activity name, implementing college, target outputs, outcomes, nature of activity, number and nature of participants, partner beneficiary details, project team, work plan, budgetary requirements, and required attachments. The form is used to recommend the conduct of an extension activity and issuance of a special order for faculty experts to serve as service providers, which requires approval from the dean of the college.

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richard babas
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96 views2 pages

Proposal Form For Extension Services

This document is an extension activity proposal form for a college. It requests information such as the extension activity name, implementing college, target outputs, outcomes, nature of activity, number and nature of participants, partner beneficiary details, project team, work plan, budgetary requirements, and required attachments. The form is used to recommend the conduct of an extension activity and issuance of a special order for faculty experts to serve as service providers, which requires approval from the dean of the college.

Uploaded by

richard babas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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EXTENSION ACTIVITY PROPOSAL FORM

Extension Activity: ______________________________________________________________

Implementing College: ___________________________________________________________

Department (s) : _________________________________________________________________

Short Project Description

a. Target Outputs : ___________________________________________________________________

b. Outcome : ________________________________________________________________________

c. Nature of Activity : ___ Skills Training ___ Knowledge Transfer/Seminar ___ Consultancy

___ Community Outreach ___ Professional Assistance ___ Professional Training

d. Number of Participants : ________________

e. Nature of Participant : ___ out of school youth ____ professionals ____ farmers ____ women

Others (pls. specify: ___________________________________________________

Profile of the Partner-Beneficiary


1. Name of Partner-Beneficiary :

2. Address of Beneficiary : 3. Telephone:

4. Fax :

5. E-Mail :

6. Contact Person: Designation :

7. Nature of Partner-Beneficiary

_____ Business : Nature of Business ( ) Service ( ) Products ( ) Both Service and products
Products/Services Offered :
_________________________________________________________
Estimated Monthly Gross Income : _____________
Registered Business ( ) Yes ( ) No Type of Ownership ( ) Sole ( ) Partnership ( )
Corporation
Number of employees : ____________________

_____ Government Agency : ( ) LGU IRA : ___________________ ( ) others , pls specify :


_______________

______ Private Organization : ( ) Association ( ) Cooperative ( ) NGOs Estimated Asset :


____________________

______ Others , pls specify : ______________________________


A. PROJECT TEAM
*Nature I hereby certify that I’m
Number of
Related Qualification and Role Hours/ of
willing to serve as Extension
Name of Members ( e.g. Guest Trainer or Resource Speaker Days to be Service
service provider for this
Recent Experience/s ; Trainer ; Consultant; Facilitator) rendered
activity*
S /V/ H/OT (signature of faculty)

*Nature of Service Legend: S- w/ Service Credit (beyond official time) V – Voluntary (beyond official; no honoraria nor service credit)
H – w/ Honoraria (beyond official time) OT – official time (no honoraria nor service credit)
B. WORK PLAN
Schedule of Activities in ____ Weeks ____ Days _____ Hours
Starting from _______________ to _________________

No. Activities /Modules/Topics Schedule of activities


(Gantt Chart)
1 2 3 4 5 6 7 8
1
2
3
4
5
6
7
8

C. BUDGETARY REQUIREMENTS

PARTICULARS FUNDED BY: (pls. Check)


( e.g. Honoraria ; supplies ; materials; rental of vehicle ; A. TSU EXTENSION
tools ; equipment )Note : pls. list down specific supplies
AMOUNT B. COLLEGE/DEPARTMENT REMARKS
C. PARTNER BENEFICIARY
and materials needed D. BENEFACTOR

A B C D

TOTAL :

D. Attachments: _____ letter of request or request form or need assessment report ___Service Contract MOA _____ Approved Module _____ Proof of Competency of the Service Provider
Others___________________________________________________________________________
Note: For Extension projects and services to be delivered by students and/or involved the participation of the students, additional documents/requirements following existing University policy and
guidelines in sending students outside school activities apply

Prepared By/date: ______________________________ ___________________________________


Program Extension Chairperson *Student Organization Representative /Adviser

I do hereby certify the correctness of the above information and recommend the conduct of the extension activity and the
issuance of Special Order to the above faculty expert/s as service provider, for approval by Professor ARNOLD R.
LORENZO Dean, College of Education

______________________________
College Dean

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