Republic of the Philippines

Department of Education
Negros Island Region
SCHOOLS DIVISION OF DUMAGUETE CITY
Dumaguete City

TEACHER’S CLEARANCE
______________________
Date

DR. EVANGEL M. LUMINARIAS, CESO V

Schools Division Superintendent
Dumaguete City

Madam:
I have the honor to submit my CLEARANCE for SY 2015-2016. This clearance indicates that I have
accounted for all money and property accountabilities and that all reports required of me have been submitted as
listed below:
Date Checked and Received by:
ITEM
Accomplished Name Signature
1. DepEd Forms: 1, 137, SF5
2. Log Sheet from June to March
3. Class Records, Grading Sheet
4. Formative Tests, Summative Tests
5. Copies of Periodical Tests from 1st to 4th Grading with
corresponding Table of Specification
6. Form 86 (P.E)
7. Assets and Liabilities/ SALN
8. School Canteen/Lunch Counter Accountability
9. Teachers League/Faculty Club Dues
10. School Property
 Textbooks, Teacher’s Manual, Curriculum Materials
 Inventory Classroom Equipment, Furnitures,etc.
 Laboratory Equipment, Tools
 Classroom Key Duplicate Key
 H.E./ Lunch Counter
 List of PTA Donations Items
11. Certification that Room is Ready for use
12. Reports:
 Narrative Reports
 Nutritional Status
 Feeding
 Food Production
 BSP/GSP Activities/ (Sustaining Membership Fund)
 NDEP
 Library
 Lunch Counter/Financial Report
13. Individual Performance Commitment Review Form
(IPCRF)
14. PHIL-IRI/EGRA/SReYA
15. DCDMPC
16. Financial Statement of PTA Donations

_________________________________
Teacher’s Signature Over Printed Name

I hereby certify that ___________________________________of ________________has satisfactory

accounted for all items listed above. Complete clearance is therefore granted this ___________, 2016.

_________________________
Principal

Endorsed by: NELSON A. CADAY Noted by: NERI C. OJASTRO, Ed.D., CESE
Chief, SGOD Assistant Schools Division Superintendent

Approved by: EVANGEL M. LUMINARIAS, Ph.D., CESO V

Schools Division Superintendent