Republic of the Philippines

Department of Education
Region 02 (Cagayan Valley)
SCHOOLS DIVISION OFFICE OF ISABELA
Alibagu, City of Ilagan, Isabela 3300
 www.deped-isabela.com.ph  (078) 323-0281/323-2015  isabela.depedro2@gmail.com

FM-SDS-ICT-004
ICTU-TAF-02
ICT EXTERNAL TECHNICAL ASSISTANCE (TA) FORM
CLIENT INFORMATION
School ID: ____________________________
School Name: ____________________________________
District: ______________________________
School Head: _____________________________________
Contact No.: _________________________
ICT Coordinator: __________________________________
Contact No.: _________________________
For DepED LIS/EBEIS User Acct. Mng’t. System:
Pls fill this up:
For DepED Email Password Creation/Reset,
Pls fill this up: Emp. No.: ________________
First Name: ___________________________________________
Middle Name: ________________________________________
Last Name: ___________________________________________
DepED Email (for Reset): _____________________________
Contact No.: ______________________________
TIN: _________________ Birthdate: __________________
For Internet Connectivity Concern/Issues:
Pls fill this up:

Request for Password Reset: Request for TA-Installation:

School Head Username: __________________________ Municipality: __________________________________________
Desired Password: ______________________ Potential Provider: ____________________________________

System Admin Username: __________________________

Desired Password: ______________________
Request for TA-Existing Subscriber:
Status: ( ) Fixed ( ) Portable
Request for Change of School Head:
Nature: ( ) Postpaid ( ) Prepaid
Name of New School Head: ________________________
Provider: _______________________________
TIN (New School Head): _____________________
Average Spending: ____________________
Date of Birth: ______________________

Name of Prev. School Head: ________________________ Remarks:

TIN (Prev. School Head): ____________________ _______________________________________________________
Date of Birth: ______________________ _______________________________________________________
_______________________________________________________

DepED Computerization Program (DCP)

DCP Batch No. ________ Date of Delivery: ______________________
Part Hardware Software Network Others
1. Printer 4. Internal 7. OS 10. Installation 13. LAN Configuration
Code 2. System Unit 5. Peripherals 8. Drivers 11. Update 14. Router/Cables
Number: 3. Monitor/Display 6. Connectors/Plugs/Power 9. Malware 12. Files/Data 15. Internet

ITEM DESCRIPTION PROBLEM/ISSUE SERIAL NO.

(Please identify Part Code Number) (Please specify) (Please refer to your Delivery Receipt)
FINDINGS

-----------To be filled up by ICT Unit-----------

STATUS/RECOMMENDATION/REMARKS:

( ) GOOD/RETURNED ( ) CHECK FOR AUTHORIZED SERVICE CENTER ( ) FOR REPLACEMENT ( ) UNSERVICEABLE

OTHER DETAILS:
School Head/Representative: Received/Noted by:

ORLANDO L. NICOLAS, JR.

Signature over Printed Name Information Technology Officer I
Date:_________________________ Date:_________________________

FM-SDS-ICT-005 REV. 00