Extension Load Credit (Elc) : Application Form

ELC Form 1 (revised June 2019) Term
Select Sem A.Y. YYYY - YYYY

EXTENSION LOAD CREDIT (ELC)
APPLICATION FORM
FACULTY INFORMATION
1. Name 2. Sex
Last Name, First Name, M.I. Ma le Fe ma le
3. College/Unit 4. Inst./Dept./Division 5. Faculty Position 6. Nature of Appointment
Select here Type here Select here Select here
EXTENSION WORK INFORMATION

(Use separate form for more than one project)
7. Project Title
Type complete title here
8. Geographic Location of Extension Work (Province/Municipalities/Barangay)
Select here Please specify
9. Type of Extension Activity For other type of extension activity… 10. Nature of Involvement
Select here Please specify Type here
11. Subject Area of Interest For other subject area of interest… 12. START DATE 13. EXPECTED END DATE
Select here Please
specify
14. Target Beneficiary/Group/Sector For other target beneficiary… 15. Funding Agency Classification
Select here Please specify Select here
16. Name of Funding Agency
Type here
LOAD CREDIT INFORMATION

17. Total ELC Unit/s Requested 18. Application Status 19. Are you also applying for RLC/CWLC this SEMESTER? How many unit/s? ____
(If yes, please attach a photocopy of your application)
Click here Select here Select here
20.
I certify that all information/data in this form are true and correct to the best of my knowledge. I understand that a report or proof of
output is to be submitted to OVCRD thru OEC at the end of the semester or term for which ELC is granted and at the end of the
project period. I further certify that I have no overdue accountabilities for OEC-funded and managed projects.
___________________________________ Date: _______________________

Applicant’s Signature over Printed Name
21.
RECOMMENDATION ELC TOTAL UNIT/S RECOMMENDED
We certify that we have reviewed this ELC application and that the requested extension load credit/s was/were pre-assigned based on the
College/Unit’s approved Extension Work Agenda for the Academic Year. We further certify that this application complies with the
College/Unit’s detailed guidelines for extension work and were evaluated by the College Executive Board or equivalent body.
Signature over Printed Name of Dept. Chair Signature over Printed Name of College Dean/Unit Director
(Position) (Position)
Date: Date:
ENDORSEMENT/ APPROVAL: ELC TOTAL UNIT/S APPROVED
________________________ ___________________________ ___________________________

LENORE P. DELA CRUZ FIDEL R. NEMENZO, D.Sc. EVANGELINE C. AMOR, Ph.D.
OEC Director Vice-Chancellor for Research and Development Vice-Chancellor for Academic Affairs
EXTENSION WORK CAPSULE PROPOSAL
PART 1. DETAILS OF THE PROPOSAL
1.1 Extension Project Title
1.2 Key Words to Describe Subject Area of Extension Work (Maximum of 5)
1.3 Abstract
 Please provide a brief summary of the proposed extension work/project. Maximum of 500 words.
1.4 College/Unit Extension Work Agenda Theme/Topic

(Please attach a copy of the most recent / updated Extension Agenda approved by the College/Unit, highlighting the specific theme/topic that the project is most associated)
1.5 Objectives
 Please state the general and specific objectives addressed by the proposed extension work.
1.6 Methodology
 Describe the systematic project design or plan to achieve the desired objectives, specifying the key strategies / components and activities to be undertaken.
 Please attach the request for the extension work from the partner organization (if applicable).
1.7 Work Plan and Schedule of Activities

 Present in a GANTT chart the critical activities to be undertaken in chronological order for every major phase of the extension work (add columns as necessary), e.g.:
 Preparatory/Conceptualization/Development of ideas
 Project implementation
 Report writing/Post-production/Exhibition/Distribution
Timeframe (e.g., Months Covered)

Project Phase/Key Activities
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6
 Indicate if there is any plan of getting funding (UP Diliman, UP System, others)
 Indicate the PERCENT OF WORK ACCOMPLISHED (%) in case of renewal (for the same extension work/project) Percent %
1.8 Expected Output

 Please describe the expected output of the extension work. Output may be any of the following:
 Training modules or manual developed  Software or computer program developed from the project
 Full proceedings/ documentation of the extension project  Full paper submitted to a reputable peer-reviewed journal and letter of receipt of
 Full paper in conference/ symposium/ colloquium proceedings acknowledgement
 Proof of exhibition or equivalent in visual and/or performing arts  Others, please specify
PART 2. CERTIFICATION
I certify that all information/data in this proposal are true and correct to the best of my knowledge. I understand that a report or proof of
output is to be submitted to OEC at the end of the semester or term for which ELC is granted and at the end of the project period. I further
certify that I have no overdue accountabilities for OVCRD-funded and managed projects.
Signature over Printed Name Date

Extension Load Credit (Elc) : Application Form

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Extension Load Credit (Elc) : Application Form

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ELC Form 1 (revised June 2019) Term

Select Sem A.Y. YYYY - YYYY

EXTENSION WORK INFORMATION

LOAD CREDIT INFORMATION

_____________ Date: _

ENDORSEMENT/ APPROVAL: ELC TOTAL UNIT/S APPROVED

__________ _ _______________

PART 1. DETAILS OF THE PROPOSAL

1.1 Extension Project Title

1.2 Key Words to Describe Subject Area of Extension Work (Maximum of 5)

1.4 College/Unit Extension Work Agenda Theme/Topic

1.7 Work Plan and Schedule of Activities

Timeframe (e.g., Months Covered)

1.8 Expected Output

Signature over Printed Name Date

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