Uctc.upm.edu.my



| |NOTA : Jika terdapat sebarang perubahan seperti dalam borang asal, sila pohon kelulusan dari pihak Urusetia. |

| |NOTE : If there any changes in the original form, kindly get approval from Secretariat. |

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|*Sila tanda (√) di ruang yang berkenaan / Please tick (√) in the appropriate space. |

|A : MAKLUMAT PROGRAM/ Information of Programme |

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|KOD RUJUKAN/NAMA PROGRAM: | |

|Reference Code/Name of Programme: | |

|B : MAKLUMAT KETUA PROJEK / Details of Project Leader |

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|NAMA KETUA PROJEK : | |

|Name of Project Leader: | |

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|FAKULTI/JABATAN/UNIVERSITI: | |

|Faculty/School/Centre/University: | |

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|(Alamat Penuh/Full Address): | |

| |NO. TELEFON PEJABAT : |NO. FAKSIMILI : |NO. TELEFON BIMBIT: |ALAMAT EMEL: |

|DIREKTORI : |Office Phone No.: |Fax No.: |Mobile No.: |E-mail Address: |

|Directory : | | | | |

|C : MAKLUMAT PROJEK / Details of Project |

|TAJUK PROJEK/AKTIVITI : | |

|Title of Project/Activity: | |

| |OBJEKTIF BERDASARKAN PERMOHONAN / |SILA TANDAKAN (√) SEKIRANYA MENCAPAI OBJEKTIF/ |

|OBJEKTIF PROJEK: |Objective(s) based on application: |Please tick (√) If objective(s) achieved: |

|Objective(s) of Project: | | |

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|Sila senaraikan objektif asal dan | | |

|perubahan objektif , sekiranya ada | | |

|Please list down original and changes | | |

|objective(s), if any. | | |

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| | |SILA TANDAKAN (√) SEKIRANYA MENCAPAI OBJEKTIF/ |

| |PERUBAHAN OBJEKTIF/ Changes Objective(s): |Please tick (√) If objective(s) achieved: |

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|TEMPOH PROJEK : |

|Duration of Project: |

|NO |SENARAI RAKAN KERJASAMA LAIN YANG TERLIBAT : (cth: |BILANGAN |BENTUK SUMBANGAN | |

| |Fakulti/Pusat/Institusi/ Agensi awam/swasta/NGO/dll) |PEGAWAI/ PELAJAR|(SUMBER TENAGA/PERALATAN/TUNAI/ IN-KIND) |JUMLAH ATAU NILAI DALAM RM |

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|E : MAKLUMAT KOMUNITI |

| | |BILANGAN KOMUNITI YANG MENERIMA MANFAAT: |

|NAMA KOMUNITI YANG MENERIMA MANFAAT: | | |

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| | |JAWATAN KETUA PENGHUBUNG / KOMUNITI : |

|NAMA KETUA PENGHUBUNG KOMUNITI : | | |

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|ALAMAT KOMUNITI : | |

|Address of Community: | |

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|MAKLUMAT PERHUBUNGAN : |NO. TELEFON PEJABAT : |NO. FAKSIMILI : |NO. TELEFON BIMBIT: |ALAMAT EMEL: |

|Contact Person: |Office Phone No.: |Fax No.: |Mobile No.: |E-mail Address: |

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|F : MAKLUMAT KEWANGAN (GERAN, PERBELANJAAN DAN SUMBANGAN / |

|Details of Financial (Grant, Expenses and Contribution ) |

|JUMLAH GERAN UCTC YANG DILULUSKAN: | RM |BAKI GERAN SEMASA |PERATUS BELANJA |

|Amount of UCTC Grant Approved : | | | |

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| |PERINCIAN SUMBANGAN (NYATAKAN) |RM (TUNAI) |PERINCIAN SUMBANGAN (NYATAKAN) |NILAI ANGGARAN /IN-KIND (RM) |

|LAIN-LAIN SUMBANGAN (TUNAI ATAU IN-KIND) | | | | |

|KEPADA PROJEK SEHINGGA KINI: | | | | |

|Others Contribution According to Progress: | | | | |

|G : STATUS PROJEK / Status of Project |

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|ILMU YANG DIPINDAHKAN SEHINGGA KINI: |ISU/ MASALAH/ CABARAN: |TINDAKAN YANG DIAMBIL UNTUK MENANGANI ISU/ MASALAH/ |TEMPOH MASA MENANGANI ISU/MASALAH/CABARAN: |

|Knowledge Transferred According to |Issues/ Problems/ Challenges: |CABARAN: |Duration to Overcome Obstacles: |

|Progress: | |Action Taken to Overcome/Issues/ Problems/ Challenges: | |

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|Sila gunakan lampiran tambahan jika perlu/ Kindly use additional sheet if necessary |

|H : HASIL DAN IMPAK BERDASARKAN ‘MILESTONE’ DAN PROGRES KEPADA KOMUNITI / Outcome and Impact based on Milestone and Progress to community |

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|HASIL PENCAPAIAN MENGIKUT ‘MILESTONE’ DAN |‘MILESTONE’ / |HASIL/ |IMPAK/ |

|PROGRES BESERTA PERATUS KEPADA KOMUNITI: |Milestone |Outcome |Impact |

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|PULANGAN KEPADA IPTA: |HASIL/ Outcome |IMPAK/ Impact |

|Return(s) to IPTA : | | |

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|HASIL TIDAK LANGSUNG YANG DITERIMA OLEH | |

|KOMUNITI (SASARAN): | |

|Indirect Outcome received by recipient | |

|Industry / Community (Targeted): | |

| |*Sila gunakan lampiran tambahan jika perlu/ Kindly use additional sheet if necessary. |

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|HASIL TIDAK LANGSUNG YANG DITERIMA OLEH PIHAK KETIGA(BUKAN SASARAN): | |

|Indirect Outcome received by third party: | |

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| |* Sila gunakan lampiran tambahan jika perlu/ Kindly use additional sheet if necessary. |

|GAMBAR PROGRAM DALAM BENTUK SOFT COPY |Tandakan ( / ) |

| |ADA: TIADA: NAMA FAIL DOKUMEN GAMBAR: |

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| |ADA: TIADA: NAMA FAIL DOKUMEN GAMBAR: |

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|I : AKUAN KETUA PROJEK / Declaration by Project Leader |

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|TANDATANGAN KETUA PROJEK : ____________________________ TARIKH : |

|Project Leader’s Signature : (Tandatangan Elektronik) Tarikh: |

|(Electronic Signature) |

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|J : AKUAN URUSETIA / UCTC UNIVERSITI YANG BERTANGGUNGJAWAB |

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|NAMA PUSAT BERTANGGUNGJAWAB: | |

|Name of Responsible Center : | |

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|NAMA URUSETIA/UCTC UNIVERSITI YANG BERTANGGUNGJAWAB: | |

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|TANDATANGAN : ____________________________ TARIKH : |

|(Tandatangan Elektronik) Tarikh: |

|(Electronic Signature) |

|K : RESPON DARI SEKRETARIAT/Response By Secretariat |

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|UNTUK KEGUNAAN SEKRETARIAT SAHAJA/ For Secretariat Use Only |

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|NO. |

|BAHAGIAN / PART |

|LENGKAP / Complete |

|TIDAK LENGKAP / Incomplete |

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|1 |

|A : |

|MAKLUMAT PROGRAM |

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|B : |

|MAKLUMAT KETUA PROJEK / Details of Project Leader |

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|C : |

|MAKLUMAT PROJEK / Details of Project |

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|D : |

|MAKLUMAT RAKAN KERJASAM LAIN |

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|E : |

|MAKLUMAT KOMUNITI |

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|F : |

|MAKLUMAT KEWANGAN (GERAN, PERBELANJAAN DAN SUMBANGAN ) |

|Details of Financial (Grant, Expenses and Contribution ) |

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|G : |

|STATUS PROJEK / Status of Project |

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|H : |

|HASIL DAN IMPAK BERDASARKAN ‘MILESTONE’ DAN PROGRES KEPADA KOMUNITI |

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|I : |

|AKUAN KETUA PROJEK / Declaration by Project Leader |

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|J : |

|AKUAN URUSETIA/UCTC UNIVERSITI YANG BERTANGGUNGJAWAB |

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|UCTC |

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|KEMENTERIAN PENDIDIKAN MALAYSIA |

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|TEL : FAKS: |

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-----------------------

PROGRAM UCTC

KEMENTERIAN PENDIDIKAN MALAYSIA

LAPORAN PROGRAM / PROGRAMME REPORT

VIDEO PROGRAM

[pic]

TERIMA/ Received

DIKEMBALIKAN/Returned

ULASAN / Comments:

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