Republic of the Philippines

Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 4: INNOVATION PROJECT PROPOSAL TEMPLATE

I. Proponent/s
(Write the name/s of the proponent/s, positions, and brief description of roles
and responsibilities in the Innovation Project)

Lead (Name)
Proponent: (Position)
(Brief Description of Roles and Responsibilities in the Innovation Project)
Co-Proponent*: (Name)
(Position)
(Brief Description of Roles and Responsibilities in the Innovation Project)

Co-Proponent*: (Name)
(Position)
(Brief Description of Roles and Responsibilities in the Innovation Project)

*If needed.

II. Implementing Entity:

(Indicate the Functional Division/Unit/Section/School)

III. Type of Innovation

(Indicate the type of Innovation: Process or Product)

IV. Brief Description of the Proposal:

(Briefly describe the innovation in terms of its type, project target, usage or
application, and its significance)

V. Scope of Implementation:
(Specify the Scope: Regional/Division/School)

VI. Total Funding Requirement:

 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

(Indicate the amount of funds needed for the innovation project and source)

VII. Implementation Period:

(Please specify the duration for implementing the innovation project)

VIII. Background
(Please provide the circumstances or situation that led to the proposal for the
innovation project.)

IX. Rationale
(Indicate data-driven reasons why the innovation is necessary [refer to
sources of innovation], and what needs to be addressed or innovated)
X. Project Description
(Provide information for the following)

A. Goal:

B. Outcome:

C. Objectives:

D. Inputs:

E. Expected Outputs:
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

F. Logical Framework (LogFrame)

(Lay out the overview process, inputs, activities, outputs, and outcome)

XI. Methodology

A. Method (Briefly discuss the design)

B. Target Beneficiary

C. Impact Estimation

D. Work and Budget Plan

(Action Plan reflecting specific strategies, activities, and resources)

Phase Activity Time Resources Budgetary Expected

Frame Human Material Financial Requirement Output/s
Pre-
Impleme
ntation
Impleme
ntation
Post-
Impleme
ntation

E. Monitoring and Evaluation Plan

No. INDICATOR BASELINE TARGET DATA FREQUENCY RESPONSIBLE REPORTING

SOURCE
(What is (What is (How often (Who will (Where will
the the (How will it will it be measure it?) it be
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

current target be measured?) reported?)

value?) value?) measured?)

F. Exit Plan
(Exit strategy should clarify how your project will be brought to a close while
sustaining its benefits)
Plan Component/Method Action Steps Timeline
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 5 – DECLARATION OF ANTI-PLAGIARISM AND ABSENCE OF CONFLICT

OF INTEREST

Declaration of Anti-plagiarism

1. I/We, ___________________________, ___________________________,

___________________________, 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/We hereby attest to the originality of this innovation project proposal and
have cited properly all the references used. I/We further commit that all
deliverables and the final innovation project emanating from the proposal
shall be of original content. I/We shall use appropriate citations in
referencing other works from various sources.

3. I/We understand that violation of this declaration and commitment shall be

subjected to consequences and shall be dealt with by the Department of
Education.

___________________________________
Signature over Proponent’s Name
Date: ________________

___________________________________
Signature over Proponent’s Name
Date: ________________

___________________________________
Signature over Proponent’s Name
Date: ________________
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

Declaration of Absence of Conflict of Interest

1. I/We, ___________________________, ___________________________,

___________________________, understand that conflict of interest refers to
situations in which financial or other personal considerations may
compromise my judgment in implementing, evaluating, and reporting the
innovation.

2. I/We declare that I/we do not have a personal conflict of interest that may
arise from my application and submission of my/our innovation proposal.
I/We understand that my/our innovation proposal may be returned to
me/us if found out that there is a conflict of interest during the initial
screening.

3. Further, in case of any form of conflict of interest (possible or actual) which

may inadvertently emerge during the conduct of my/our innovation, I/we
will duly report it to the innovation committee for immediate action.

4. I/We understand that I/we may be held accountable by the Department of

Education for any conflict of interest which I/we intentionally concealed.

___________________________________
Signature over Proponent’s Name
Date: ________________

___________________________________
Signature over Proponent’s Name
Date: ________________

___________________________________
Signature over Proponent’s Name
Date: ________________
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 6 – GUIDE FOR APPRAISING INNOVATION PROJECT PROPOSALS

Increasing Levels of Quality and their Descriptions
Criterion Low High Score
Rationale for the Not The innovation proposal presents The reason for the The nature and extent of the
Innovation Provided a general description of the need innovation is indicated concerned area are comprehensively
(No point) for innovation. specifically but discussed discussed. The priority
less comprehensively improvement area is clearly
identified. Root cause analysis/
(30 Points) research findings/recommendation
(11-20 Points) or needs assessment is indicated to
support the need for innovation.
(21-30 Points)
(1-10 Points)

Alignment of the Not The alignment innovation proposal The suggested innovation's alignment with the rationale is clearly
Proposed Innovation evident is less evident in the rationale. indicated.
to the Rationale
(10 Points) (No point) (1-5 Points) (6-10 Points)

Feasibility of the Not Scope reflects a limited The proposal includes a The proposal demonstrates
Innovation feasible understanding of feasibility. The strategy for developing a consideration of the feasibility and
proposed project may be too large timeline and reaching appropriateness of the project;
or too small to complete in the intended beneficiaries. includes detailed work and work
(10 Points) (No point)
timeframe. plans.
(4-7 Points)
(1-3 Points) (8-10 Points)

Potential Impact of Not clear Assessment of the potential impact Assessment of the potential impact of the innovation uses clear
the Innovation to (No point) is poor, too general, or does not data analysis to assess improvement. The assessment has a clear
Improve the use any metrics. reference to a baseline.
Concerned Area
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

(30 Points)
(1-15 Points) (16-30 Points)

Completeness of The innovation proposal is The innovation misses at The innovation proposal is
Innovation Proposal significantly incomplete and lacks most two requirements for organized and contains all the
more than two requirements for the proposal. requirements for the proposal.
(20 Points) the proposal.
(1-6 Points) (7-14 Points) (15-20 Points)

Total ____/100
Remarks:
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 7 – SAMPLE LETTERS OF APPROVAL AND DISAPPROVAL

Letter of Approval

[Insert Date]

Mr./Ms. ______________
_______________________
_______________________

Dear Mr./Ms. ___________:

Greetings!

We are pleased to inform you that your innovation project proposal titled
__________________________________, which was submitted to the [insert
governance level] and was thoroughly evaluated by the Innovation Committee
based on the criteria prescribed in the Regional Implementation Guidelines on
Innovation Management, has been approved for implementation. Please be aware
that the Innovation Committee Secretariat shall monitor the progress of your
innovation project throughout its implementation.

For clarifications and any concerns, kindly contact [insert contact office, focal
person, and contact details].

We look forward to the successful implementation of your innovation.

Congratulations!

Very truly yours,

INNOVATION COMMITTEE CHAIR

 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

Letter of Disapproval

[Insert Date]

Mr./Ms. ______________
_______________________
_______________________

Dear Mr./Ms. ___________:

The Innovation Committee has carefully evaluated your innovation project proposal
titled __________________________________ based on the criteria prescribed in the
Regional Implementation Guidelines on Innovation Management.

We regret to inform you that the said proposal did not pass the evaluation due to
the following reasons:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Kindly take note that you can still re-submit your innovation project proposal once
all comments and recommendations are incorporated.

For clarifications and any concerns, kindly contact [insert contact office, focal
person, and contact details].

We look forward to future collaboration with you. Thank you very much.

Very truly yours,

INNOVATION COMMITTEE CHAIR

 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 8 – PROGRESS IMPLEMENTATION MONITORING OF INNOVATION PROJECT TEMPLATE

Title of Innovation: ____________________________________________________________ Date of Monitoring: ________________

Proponent/s: ____________________________________, _________________________________, ___________________________________

Status Technical
Activity
Issue/s encountered Assistance Agreement
(Based on Workplan) Completed On-going Provided

Prepared by:

NAME INNOVATION SECRETARIAT MEMBER/S

 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 9 – COMPLETED INNOVATION PROJECT REPORT TEMPLATE

I. Cover Page
II. Table of Contents
III. Executive Summary
IV. General Objective of the Innovation
V. Description of the Innovation
VI. Activities Undertaken during the Implementation
VII. Highlight Accomplishments/Improvements made by the innovation in the
concerned area. Indicate the impact of the innovation to be supported by
statistical analysis.
VIII. Budget Utilization (actual)
IX. Sustainability
X. Appendices
A. Approved Innovation Proposal
B. Certificate of Utilization
C. Certificate of Adoption, if adopted by another school/office
D. Data Analysis Report/Actual Computation of Raw Data
E. Pictorials
F. Minutes of the Meetings, if there are
G. Attendance logs, if necessary
H. Other significant/relevant supporting document
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 10– CERTIFICATE OF UTILIZATION OF INNOVATION

Certificate of Utilization of Innovation

This is to certify that the innovation entitled ________________________

____________________________________________________, introduced and implemented
by ______(Proponent/s)_______________ was fully utilized during from __date___ to
__date___ at [school/office].

Given this ____ day of _________, 20__ at [school/office].

____________________________________
Head of Office
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 11 – CERTIFICATE OF ADOPTION OF THE INNOVATION PROJECT BY

ANOTHER SCHOOL/OFFICE

Certificate of Adoption of the Innovation

This is to certify that the innovation project submitted and approved by this office,

Title of the Innovation:

______________________________________________
______________________________________________
______________________________________________
Proponent/s:
______________________________________________
______________________________________________
______________________________________________
School/Unit/Section/Division:
______________________________________________

has been adopted and implemented by other concerned users/personnel from

_(date)______ to _(date)______ as manifested through the attestation by the
school/unit/section/division head below. This is issued for whatever legal purpose
it may serve this ___day of the month of ______ 20__.

____________________________________
Head of Office
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

ANNEX 12– END INNOVATION PROJECT OUTCOME AND IMPACT EVALUATION TEMPLATE

Title of Innovation: ____________________________________________________________ Date of Monitoring: ________________

Proponent/s: ____________________________________, _________________________________, ___________________________________

A. Innovation Accomplishments

Phase Activity Status Remarks

Achieved Not Achieved

1. Pre-
Implementation

2. Implementation

3. Post-
Implementation

B. Outcome and Impact Evaluation

Area Status

Fully Evident (FE) Partially Evident (PE) Not Evident (NE)

1. Relevance (on alignment and consistency with national priorities

and policies, on responsiveness to stakeholder needs, on
complementation with other programs/projects, and programmatic
alternatives)
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF TARLAC PROVINCE

2. Effectiveness (on achievement of objectives, on unintended results,

and on timeliness such as learning outcomes, access, equity, or
client satisfaction)

3. Efficiency (on efficient delivery of outputs and operational

alternatives

4. Sustainability (on having a defined strategy for accomplishing long-

term objectives to maintain the innovation's programs and activities)

Evaluated by:

_________________________________________________
Assistant Schools Superintendent

________________________________ _____________________________________ ______________________________

Member Member Member

________________________________ _____________________________________ ______________________________

Member Member Member
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON

ANNEX 13 – OUTCOME AND IMPACT VALIDATION CERTIFICATE TEMPLATE

Certificate of Outcome and Impact Validation of Innovation

This is to certify that the outcome and impact of the innovation titled ____________
____________________________________________________, introduced and implemented
by ______(Proponent/s)_______________ was validated by the Innovation Committee
based on the End Project Impact and Outcome Evaluation criteria prescribed in the
Region's Implementation Guidelines on Innovation Management.

Given this ____ day of _________, 20__ at [school/office].

Recommending Approval:

____________________________________
Assistant Regional Director/Assistant Schools Division Superintendent

Approved:

_______________________________________________________
Regional Director/ Schools Division Superintendent
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON

ANNEX 14 – CONSENT AND ASSENT LETTERS (IN CASE THE INNOVATION

PROJECT INVOLVES MINORS AS PARTICIPANTS)

Consent Letter
Date: _______________________

Dear Parent or Guardian:

Greetings!
I/We am/are currently conducting an innovation project entitled _______(Title of the
Project)_____________________________________________. The project primarily aims to
________________________________________. In line, I/we humbly request your
permission for your child to participate in the project.

(Briefly state the participation of the child in the

project)_____________________________________________. The participation of your
child will be explained in terms that your child can understand, and your child will
participate only if he or she is willing to do so. At the conclusion of the project,
learners’ responses will be reported as group results only.
Participation in this study is voluntary. Your decision whether or not to allow your
child to participate will not affect the services normally provided to your child by
the school. Your child’s participation in this study will not lead to the loss of any
benefits to which he or she is otherwise entitled. Even if you give your permission
for your child to participate, your child is free to refuse to participate. If your child
agrees to participate, he or she is free to end participation at any time. You and
your child are not waiving any legal claims, rights, or remedies because of your
child’s participation in this innovation project.
Any information that is obtained in connection with this project and that can be
identified with you will remain confidential and will be disclosed only with your
permission or as required by law. All data will be dealt with utmost confidentiality.

Should you have any questions or desire further information, please call/text me at
____________ or email me at ______________. Keep this letter after tearing it off (if this
is to be done) and complete the bottom portion and send the Reply Slip online.
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON

Sincerely,
___________________________________
Signature over Proponent’s Name
Date: ________________

___________________________________
Signature over Proponent’s Name
Date: ________________

___________________________________
Signature over Proponent’s Name
Date: ________________

----------------------------------------------------------------------------------------------------------------
Reply Slip
Please indicate whether or not you wish to allow your child to participate in this
project by checking one of the statements below, and signing your name. Sign both
copies and keep one for your records.
_____ I grant permission for my child to participate in the innovation project on
“_________________________”
_____ I do not grant permission for my child to participate in the innovation project
on “_______________________________”.

______________________________ ______________________________
Printed Parent/Guardian Name Signature of Parent/Guardian
______________________________ ____________________________
Printed Name of Child Date

ASSENT TO PARTICIPATE IN THE PROJECT

1. I/We am/are (Name)____________________________________________________.
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON

2. Currently, I/we am/are conducting an innovation project entitled

____________________________________________. This project primarily aims to
__________________________________________________________________________.

3. If you agree to be part of the project, I/we will ask you to (Specifically state
the child’s participation in the project).

4. Your participation in this project is voluntary. Your participation in this

project will not lead to the loss of any benefits to which you are otherwise
entitled. You are free to refuse to participate. If you agree to participate, you
are free to end participation at any time.
5. Any information that is obtained in connection with this project and that can
be identified with you will remain confidential and will be disclosed only with
your permission or as required by law. All data will be dealt with utmost
confidentiality.
6. Should you have any questions or desire further information, please
call/text me/us at ________________ or email me/us at _____________.
7. Signing your name at the bottom means that you agree to be part of this
project.

________________________________________
Signature of Participant
________________________________________ ____________________
Printed Name of Participant Date

The template is adapted from Michigan Tech (https://www.mtu.edu/research/administration/research-integrity/review-boards/human-subjects/consent-

forms.html)

SAMPLE INDORSEMENT
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON

1st Indorsement
September 11, 2023

Respectfully forwarded to RONNIE S. MALLARI, PhD, CESO V, Schools

Division Superintendent, Schools Division of Tarlac Province, herein innovation project
proposal of Mr. Juan dela Cruz, Teacher II of ___________________titled
“_________________________________, for appropriate action.

NAME OF IMMEDIATE SUPERVISOR

Position
Signature Over Printed Name

Recommending Approval:

NAME OF DISTRICT SUPERVISOR

Signature Over Printed Name

TEMPLATE OF SIGNATORIES

Prepared by:
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON

John Dela Cruz

Proponent

Evaluated and Reviewed by:

Focal person of concerned division/learning area/section/program

Noted:

Chief Supervisor of concerned division/learning

area/section/program

Recommending Approval:

ASDS Maria Celina L. Vega for CID concern

Assistant Schools Division Superintendent

ASDS Armando C. Capili for SGOD concern

Assistant Schools Division Superintendent

Approved:

SDS Ronnie S. Mallari, PhD, CESO V

Schools Division Superintendent