Republic of the Philippines

Department of Education
Regional Office I
Quality Assurance Division

APPLICATION FORM FOR OPENING SENIOR HIGH SCHOOL (SHS) PROGRAM (PUBLIC SCHOOL)

Region/Division: _______________________________________ School Name : __________________________________________________________

Contact Person : _______________________________________ Address : __________________________________________________________
Designation : _______________________________________ Contact No. : __________________ E-mail Address: ___________________________
Date of Application: ____________________________________ SY of Intended Operation: ________________________________________________

REQUIREMENTS

REMARKS/FINDINGS
ITEM √ or X
Document Evaluation Ocular Inspection
A. REQUIRED DOCUMENTS
1. DepEd School Identification (ID)
2. Letter-request/Letter of Intent for implementation of
the SHS program addressed to the Schools Division
Superintendent (SDS).
3. Certification signed by the SDS stating that no public
SHS is offering the same SHS Track within the
catchment area.
a. Justification signed by the SDS, in case will offer
the same SHS Track.

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division

REMARKS/FINDINGS
ITEM √ or X
Document Evaluation Ocular Inspection
4. Implementation Plan for SHS program covering five
(5) years to include among others:
a. Current and projected enrolment for five (5)
school years, by grade level.
b. Proposed budgetary requirements for its Personal
Services, Maintenance and Other Operating
Expenses and Capital Outlay.
c. Operational Plan regarding curriculum and
instructional supervision of the proposed SHS.
d. School Site Development Plan to include
proposed school buildings, as needed.
5. Certification signed by the School Head, duly
attested by the SDS on the excess classrooms,
tables, chairs and other resources to be used in the
implementation of SHS program.

6. Inventory of learning resources prepared by school’s

Property Custodian, as validated by the Schools
Division Office.
7. Updated Personal Services Itemization and Plantilla
of Personnel of the concerned school.

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division
REMARKS/FINDINGS
ITEM √ or X
Document Evaluation Ocular Inspection
8. Updated Status Report with regard to the school’s
existing crucial resources.
9. Map, preferably drawn to scale, showing the vacant
lot where the proposed SHS classrooms/school
building are/ will be constructed, duly certified by the
City/Municipal Engineer.
10. List of prospective enrollees in SHS per track and
strand, indicating their names, Learner Reference
Numbers (LNRs), where applicable, ages,
addresses, school names and DepED School ID
Numbers where they are currently or previously
enrolled.
a. Justification signed by the SDS, in case the
required minimum enrolment and/or number of
tracks are not satisfied.
11. List and types of establishments and industries in the
community, as attested by the Department of Trade
and Industry, Department of Labor and Employment
or the Municipal Planning Officer.

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division
REMARKS/FINDINGS
ITEM √ or X
Document Evaluation Ocular Inspection
12. Certification from the SDS that the track/s and
strand/s to be offered are aligned with the Local
Development Plans, as evident in the list provided by
the City/Municipal Mayor, and are decided upon by
the Regional Director, SDS, Division Planning Officer
and the School Head concerned.
13. Results of internal assessments or surveys done with
the prospective enrollees.
14. List of tracks and strands to be offered, duly signed
by the Regional Director or SDS, Panning Officer and
School Head.
15. Memorandum of Agreement (MOA) executed
between the SDS and the partner entity enumerating
the respective roles of both parties.
16. Immersion deployment plan.

B. CURRICULUM OFFERING
DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division

Academic track Strand: ___________________________________________________________________________________________

Tech-Voc Track Strand: HE: ____________________________________________________________________________
ICT: ____________________________________________________________________________
IA: ____________________________________________________________________________
AFA: _____________________________________________________________________________
Arts and Design Track Strand: Performing Arts: ___________________________________________________________________
Arts Production: ___________________________________________________________________
Sports Track
Unique Track
C. MINIMUM PROGRAM REQUIREMENTS FOR THE SHS TRACKS / STRANDS
1. Instructional Rooms
2. Laboratories
2.1 Computer
2.2 Science (for STEM minimum of 3 Laboratory)
2.3 Workshop Room/Studios
3. Athletic Facilities
4. Learners’ Resource Center or Library
5. Internet Facilities
6. Ancillary Services
7. School Grounds (Check for Cleanliness, presence of
trash bin, etc.)

Reviewed By: Complete

______________________________ Incomplete REMARKS: __________________________________________________
DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division
SDO/RO Validator __________________________________________________
Date: _________________________

Remarks:

Recommended for Ocular Inspection Tracks/Strands/Specializations: ______________________________________________

______________________________________________
With Deficiencies: ______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Date of Ocular Inspection: _________________

Recommendation Action:
______ Recommended for Approval (Indicate track/strand and specializations for Tech-Voc Track)
(Specify): _______________________________________________________________________________________
_______________________________________________________________________________________________

______ Deferment:
_______________________________________________________________________________________________
_______________________________________________________________________________________________

For Revalidation on: _____________________________

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division

________________________________ _____________________________
SDO/RO Validator SDO/RO Validator
(Signature over Printed Name) (Signature over Printed Name)

Revalidated on: __________________________

REMARKS:
Recommended for Issuance of Government Permit (Indicate track/strand and specializations for Tech-Voc track)
(Specify): ______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Recommended for Deferment:

______________________________________________________________________________________________
______________________________________________________________________________________________

______________________________ ______________________________
SDO/RO Validator SDO/RO Validator
(Signature over Printed Name) (Signature over Printed Name)

Date of Review: __________________________

Action Taken:

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division

_______ For Approved Permit (Indicate track/strand and specializations for Tech-Voc Track)
_____________________________________________________________________________________________
_______ Recommend to applicant to defer operation upon completion of K to 12 SHS Program requirements
_______ Others (please specify): _______________________________________________________________________
_______________________________________________________________________

Noted By: Approved By:

OSCAR P. FLORES ____________________

Chief Education Supervisor Regional Director
Quality Assurance Division

Document Code: RO1-LQF-QAD-014

Revision: 01
Effectivity Date: 10-07-2019

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph