OUTREACH PROJECT PROPOSAL TITLE: A. Outreach Group: ___________________________________________________ B.

Brief Description and/or Rationale of the Outreach Activity/Service:

C. Target Group and Reasons for Choosing it :

D. Date of Implementation: E. Objective, Activities, Outputs, Personnel and Budgeting:

_____

Objective

Activities

Outputs

Personnel

Budget

F. Line Item Budget: (Format and Sample) BUDGET ITEM 1. Operating Costs 1.1 Supplies PARTICULARS SUBTOTAL ESTIMATED COST 00,000.00 0

1.1.1. Ink cartridge: HP (P1,000.00/pc.

1.2 Communicati on 1.3 Documentatio n 1.4 Etc. 2. Travel Costs 2.1 Fare

x 3) 1.1.2. USB: 1G (P1,000.00/pc. X 2) 1.1.3. Bond papers subs 16(P120.00/ream x 2 reams) 1.1.4. Etc. 1.2.1. Cell cards (P300/pc. x 4) 1.2.1. Etc. 1.3.1. Cassette tapes: 60 mins (P90.00/pc. x 20) 1.3.2. Batteries: Size AAA (P60.00/pair x 20) 1.3.3 Etc. 2.1.1. Bus Fares to and from Brgy Dos ( P50.00/trip x 2 x 6 trips ) 2.1.2. Rent of van/jeepney (P500/trip x 3 days x 6 trips) 2.1.3. Taxi fare within Baguio (P100 x 2 x 6 trips) 2.2.1. Meals (120/meal x 3 meals x 3 days x 6 trips) 2.2.2. Snacks (50/snack x 2 snacks x 3 days x 6 trips) 2.3.1 Etc.

0 0 0 0 0 0 0 0 00,000.00 0 0 0 0 0 0 0,000.00 0,000.00 00,000.00 000,000.00 0,000.00 0,000.00

0,000.00

00,000.00

2.2 Food Expense 2.3 Etc. 3. Others

TOTAL BUDGET G. Budget Sourcing: (Format) Counterpart of the Outreach Group Counterpart of the University Counterpart of the Target Group

Other Source/s of Funding

Total

_______________________________ Outreach Group Leader (Signature above Printed Name) Contact Information:

CP/Landline: ___________________________________________________________ Email address: _________________________________________________________

Endorsed by: _______________________________ Dean/Adviser Officer Cc: UOC/REPO Dean/Adviser OUTREACH EVALUATION AND DOCUMENTATION This shall be the format for the outreach evaluation report: I. Project Title: II. Outreach Group: __________________________________________________ III. Target Group: IV. Date of Implementation: V. Report Proper:
A. Objective, Activities, Outputs, Personnel and Budgeting: (In order to evaluate and prepare a report for the project that was implemented as, filling up this matrix with accurate data will be helpful:)

_____________________________ Extension Programs

Objective

Activities

Outputs

Personnel

Budge t

B. Discussion: (These are the guide questions that one can use in analyzing and discussing the data on the table/matrix.) 1. Were the number of personnel and the amount of budget enough to accomplish the activities? 2. Did the activities produce the desired outputs? 3. Did the activities and outputs fulfill the objective of the project? 4. Were there some changes introduced during the implementation of the project?

5. Did these changes affect either positively or negatively the implementation of the project? 6. Were there other problems encountered in the implementation of the project? If yes, were these problems addressed and how? 7. Are there any suggestions or recommendations that might be helpful in organizing a similar project in the future or for repackaging the project into an extension program? 8. Is the project helpful to the target group?

_______________________________ Outreach Group Leader (Signature above Printed Name) Endorsed by: _______________________________ Dean/Adviser Officer Cc: Dean/Adviser UOC/REPO REPO Form 16.a EMERGENCY OUTREACH PARTICIPATION REPORT FOR FACULTY AND EMPLOYEES Date: Venue: _____________________________ Extension Programs

Faculty/Employ ee

Departme nt

Responsibility

Hrs.

Signatur e

Attested by: ________________________________ Extension Programs Officer Cc: Dean UOC/REPO

REPO Form 16.b REGULAR OUTREACH PARTICIPATION REPORT FOR FACULTY AND EMPLOYEES Outreach activity:

Department involved: Date: Venue:

Faculty/Employe e

Responsibility

Hrs.

Signature

Attested by: ________________________________ Outreach Group Leader (Signature over Printed Name) Cc: Dean UOC/REPO

Noted by: ________________________________ Dean (Signature over Printed Name)

REPO Form 16.c REGULAR OUTREACH PARTICIPATION REPORT FOR STUDENTS Outreach activity:

Organization involved: Date: Venue:

Student

Responsibility

Hrs.

Signature

Attested by: ________________________________ Student Organization Head (Signature over Printed Name) Cc: SAO UOC/REPO

Noted by: ________________________________ Adviser (Signature over Printed Name)

REPO Form 17 MANIFESTATION OF CONSENT FROM THE TARGET GROUP FOR OUTREACH

Date:____________________________

To the University President:

May I inform your Office of our willingness to enter into a partnership with the (School/Department/ Student Organization) of St. Louis University in their Outreach Project entitled on (mm/dd/yy). The details of our partnership are as specified in the outreach project proposal.

(Signature above Printed Name) applicable)

Designation (if

Community/Barangay/Organization Contact Information: Address: CP/Landline: Email address: Cc: UOC/REPO

REPO Form 18 MANIFESTATION OF COOPERATION FOR OUTREACH

Date:____________________________ To the University President: May I inform your Office of our willingness to cooperate with the (School/Department/ Student Organization) of St. Louis University in their Outreach Project with the title ____. The details of collaboration are as specified in the outreach project proposal.

(Signature above Printed Name)

Designation

______________________________________________________________________ Office/Agency/Institute Contact Information: Address: ______________________________________________________________ CP/Landline: ___________________________________________________________ Email address: _________________________________________________________ Cc: UOC/REPO