PAMPANGA STATE AGRICULTURAL UNIVERSITY

Office of the President

CRISIS MANAGEMENT COMMITTEE

FORM A. APPLICATION FORM FOR CONDUCT OF LIMITED FACE-TO-FACE
CLASSES/ACTIVITIES AND ON-THE-JOB TRAINING (OJT) AND THESIS

CHECKLIST OF REQUIREMENTS:

This form shall be submitted together with the following:

 Letter of intent from the faculty member addressed to the Office of the President
 List of participating students (with their email addresses)
 Notarized parental consent of the students
 Proof of insurance with COVID-19 coverage of the students (optional)
 Proof of full vaccination of the students and faculty member
 Approved Course Guide (for Category 2 and 3)
 Plan of Work (for Co-curricular and Extra-curricular Activity)

A. DETAILS OF THE ACTIVITY

Date of Request 11/30/22

Name of the Requester Marvie M. Guinto

Department/College/
CHEFS
Office

 Category 1

Course Code and Title  Category 2

 Category 3

Type of Activity Location of the Activity

 Lecture ☑ In-campus

 Laboratory (including performance-based and _______________________________

skill-based activities)

 Major Examination (Midterm/Final Exam)

 Off Campus
 Co-curricular
_______________________________
 Extra-curricular

 Others, ____________________

Description of the Activity

(Describe the activity to be

conducted. Use separate
sheet, if needed)

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 PAMPANGA STATE AGRICULTURAL UNIVERSITY
Office of the President

Start Date of the Activity (include time) End Date of the Activity (Include time)

December 16, 2022 (6pm) December 16, 2022 (11pm)

B. PROFILE OF THE PARTICIPATING STUDENTS

Course, Year and Section CHEFS Students

Male 102
No. of Participating Students 396
Female 294

Male
No. of Students with Vaccination
Female

C. STUDENT SERVICES NEEDED

☑ Accommodation Details of the services needed:

☑ Food Services

 Others,
_________________________

D. STATEMENT OF COMMITMENT

During the conduct of the limited face-to-face classes/activities/OJT, I will:

 Ensure that the students will adhere to safety and health protocols
 Submit the post-activity report within 2-3 days after the activity

MARVIE M. GUINTO, CHP, MSHTM

Name of the Faculty

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 PAMPANGA STATE AGRICULTURAL UNIVERSITY
Office of the President

Noted: (for those directly reporting under Vice Presidents, leave this blank)

MARIELOURDE I. SACATROPEZ, DBA

Immediate Head

Recommending Approval: (for those directly reporting under Vice Presidents, leave this
blank)
MA. CRISTINA A. DIZON, MBA
College Dean/Director

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