(เขียนด้วยลายมือตัวเอง) ·...

“ครดไมมอบายมข” ปการศกษา 2562 (ปท 9)

(เขยนดวยลายมอตนเองตวบรรจง)

โปรดอานค าชแจงใหละเอยดกอนกรอกใบสมคร

ใบสมคร “ครดไมมอบายมข” ปการศกษา 2562 (ปท 9) ~ 1/22 ~

ใบสมคร “ครดไมมอบายมข” ปการศกษา 2562 (ปท 9)

ประเภท บคลากรทางการศกษา ผบรหารสถานศกษา ครผสอน อน ๆ ระบ...............................................

1. ขอมลสวนตว

ชอ – นามสกล .....................................................................................................ชอเลน.........................................................................

วน/เดอน/ป เกด .........................................อาย...........ป เชอชาต...................สญชาต........................ศาสนา.......................................

ทอย........................................................................................ ต าบล...........................................อ าเภอ..................................................

จงหวด............................................รหสไปรษณย.................... โทรศพทบาน..........................โทรศพทมอถอ.........................................

E-mail...................................................................................................ต าแหนงปจจบน.........................................................................

สถานทท างานปจจบน .............................................................................................................................................................................

สงกด.........................................................................................................................................................................................................

เปดสอนตงแตระดบชน.......................ถง......................... จ านวนคร............................คน จ านวนนกเรยน...........................คน

ทอยสถานทท างานปจจบน.....................................ต าบล..............................................อ าเภอ................................................................

จงหวด............................................... รหสไปรษณย....................... โทรศพท..................................... โทรสาร........................................

สถานภาพ โสด สมรส อน ๆ (ระบ)............................................................... มบตรจ านวน ................... คน

หนาทรบผดชอบในการท างาน.................................................................................................. ................................................................

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ความประทบใจ และภาคภมใจในชวตทเกยวกบการงดเวน เหลา, เบยร, บหร และการพนนทกรปแบบ (มใชรางวล )

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ตดรปถายหนาตรง

ขนาด 1 นว ดวย

ลวดเยบกระดาษ

โปรดกรอกขอมล ดวยลายมอตนเอง ตวบรรจง ใหครบทกขอ (มผล

ตอการพจารณา และตดตอกลบ)





2. ประวตการศกษา

การศกษาสงสด (ระบ) .....................................................คณะ…………………….……………………………..….......………..…………..……….

วชาเอก..........................................................................สถาบน................................................................................................................

การศกษาดานศาสนา หรอเกยวของกบการพฒนาจตใจดานอน ๆ

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3. ขอมลปญหาอบายมข (ตอบเฉพาะขอทตนเองเกยวของ)

3.1 ระบปญหาอบายมข ประเภทนกเรยน / ครและบคลากรในโรงเรยน / ผปกครอง

(เนนเหลา เบยร บหร และ การพนนทกรปแบบ)

นกเรยน (ระบ)....................................................... ...........................................................................................................................

ครและบคลากรในโรงเรยน (ระบ)............................................................................................ ........................................................

ผปกครอง (ระบ).............................................................................................. .................................................................. ...............

3.2 ระบปญหาอบายมข ประเภท บคคลากรทางการศกษา

(เนนเหลา เบยร บหร การพนนทกรปแบบ)

บคลากรในสถานทท างาน.............................................................................. ..................................................................................

ครและบคลากรในโรงเรยนทานรบผดชอบ ..................................................................................... .................................................

ผมาตดตอหรอใชสถานท.................................................................................................. .................................................................

4. รางวลเกยรตบตรครดไมมอบายมขททานเคยไดรบ

ไมเคย เคย ระบป พ.ศ. ทไดรบ ..............................................................





5. ประสบการณชวตทเกยวของกบอบายมข (ระบใหครบถวน ชดเจน)

ไมเคยยงเกยวกบอบายมข

เคย ไดแก 1. ดมเหลา/เบยร/เครองดมทมแอลกอฮอล/สบบหร

2. เทยวสถานบนเทงเปนประจ า

3. เสพตดการดการละเลน/การแสดง/เฟซบก/ไลน

4. เลนการพนน ลอตเตอร หวยใตดนหรอเกมสการพนนอน ๆ

5. เกยจครานการท างาน ใชเวลาท างานไปหารายไดพเศษ ไมท างานตามหนาทรบผดชอบ

6. คบหาสมาคม คบคนชวเปนมตร

7. อน ๆ ระบ ………………………………………………………………………………………………………………

6. ปจจบนขาพเจา เลกจากอบายมขเหลานแลว (หากทานไมเคยยงเกยวกบอบายมข ไมตองตอบขอน)

6.1 เหลา/ เบยร/เครองดมทมแอลกอฮอล เลกดมมาแลว นอยกวา 1 ป 1 - 3 ป มากกวา 3 ป

6.2 บหร เลกสบมาแลว นอยกวา 1 ป

1 - 3 ป มากกวา 3 ป

6.3 การพนน เลกเลนมาแลว นอยกวา 1 ป


6.4 หวยใตดน/ ลอตเตอร เลกเลนมาแลว นอยกวา 1 ป






7. ใหระบแรงบนดาลใจจากประสบการณจรงของทาน โดยเขยน เลาเรองใหครบถวน ชดเจน อานเขาใจ โดยแรงบนดาลใจม 2 กรณ และเลอกเพยง 1 กรณ ( แรงบนดาลใจเปนเรองสวนบคคลทไมสามารถคดลอกกนได ) 7.1 แรงบนดาลใจ ทท าใหทานไมเกยวของกบอบายมข (เนน เหลา, เบยร, บหร, และการพนนทกรปแบบ) และวธการปฏบตหรอปฏเสธ ทท าใหทานปลอดอบายมข (1 หนา A4 ประมาณ 35 บรรทด) 7.2 แรงบนดาลใจ ทท าให เลกอบายมขส าเรจ จนถงปจจบน (เนน เหลา, เบยร, บหร และการพนนทกรปแบบ) และวธปฏบตทท าใหทาน เลก อบายมข ไดส าเรจ จนถงปจจบน ( 1 หนา A4 ประมาณ 35 บรรทด) ........................................................................................................................................................................................................ ...........(1)

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8. การด าเนนชวตในปจจบนทเปนแบบอยางแกนกเรยน คนรอบขาง รวมทงสงททานไดชวยเหลอ หรอท าประโยชนแกนกเรยน

ชมชน และสงคมดาน การลด ละ เลก อบายมข (1 หนา A4 ประมาณ 35 บรรทด)

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9. ผลงานโดดเดน 1 - 3 ผลงาน ททานเปนผคดรเรม รบผดชอบ และด าเนนการตอเนองจนประสบผลส าเรจ มพฒนาการ หรอแม

ยงไมส าเรจแตยงท าตอเนองจนถงปจจบน ในการ ลด ละ เลกอบายมข ในกลมเปาหมายททานท า (นกเรยน/ บคลากรการศกษา/

หนวยงานททานสงกด/ชมชน) เนนเรองเหลา เบยร เครองดมทมแอลกอฮอลทกชนด บหร และการพนนทกรปแบบทด าเนนการแลว

ระหวางป พ.ศ. 2559 - 2562 โดยเปนผลงานยอนหลงไมเกน 3 ป

เขยนเลาเรองใหเขาใจ ชดเจน ครบถวนตามประเดน (ดานลาง) ความยาวไมเกน 2 หนา A 4 (ไมรวมภาพประกอบ) โดยใหมภาพประกอบไมเกน 4 ภาพ ตอหนงผลงาน

ถามบคคล ทสามารถ ลด เลกจากอบายมข จากการด าเนนงานของทาน สามารถระบชอ ทอย เบอรโทรศพทได จะมผลตอการพจารณา

ถาม 1 ผลงาน แตเปนการท างานตอเนอง ระหวางป พ.ศ. 2559 - 2562 ใหเขยนรายละเอยดในการท างานของทาน ในแตละป และผลทเกดขนในแตละป วามผลอยางไรบาง

ประเดนทตองมในการเขยนผลงานโดดเดน ททานเปนผคดรเรม รบผดชอบ (ขอ 9) - ชอผลงาน

- แรงบนดาลใจทท าเรองน - ระยะเวลาในการด าเนนงานตงแต..........................ถง........................... - กลมเปาหมายทตองการใหพนจากอบายมขคอใคร (เนนเหลา เบยร บหร การพนน) ระบปรมาณ และคณภาพ - บทบาทหนาทของทานตองานน - สภาพปญหา กอนด าเนนการ(ระบใหครบถวน ชดเจน) และเปาหมายทตองการใหเกดขน - วธการด าเนนงาน (ระบใหครบถวน ชดเจน /ท าอะไรบาง และท าอยางไร) - ผลส าเรจทไดรบและปรากฏเปนเชงประจกษ (ไมเนนรางวลแตเนนทกลมเปาหมายมการเปลยนแปลงอยางไร) - มการพฒนาตอหรอไม ถามท าอยางไร ผลเปนอยางไร (ตามสภาพจรง) - ปจจยความส าเรจในการด าเนนงานน ทสงผลตอการลด ละ เลก อบายมข มาจากอะไรบาง - ความรสก และความคดเหนของทานตองานชนน - ขอมลอน ๆ ทตองการเพมเตม (ถาม)

ลกษณะผลงานโดดเดนททานคดรเรม รบผดชอบ - ทานคดขนเอง จากสภาพปญหาอบายมขทพบ (เนนเหลา เบยร บหร การพนน) ซงไมจ าเปนตองท าทงโรงเรยน โดยทานท าในหองเรยน หรอวชาทสอน หรอในสวนงานทรบผดชอบ และท าอยางตอเนอง มการตดตามผลทเกดขน (ไมเนนเดนรณรงคตามวาระรณรงคตาง ๆ ในแตละป) - ทานเปนผน าโครงการ จากองคกรภายนอกทเกยวของกบการปองกน แกไขปญหาเหลา เบยร บหร การพนน ทกรปแบบ เขาสโรงเรยน โดยทาน...เปนผมบทบาทหลกในการขบเคลอน และมการตดตามผล ซงโครงการดงกลาว มผลตอการปองกนแกไขปญหาเหลา เบยร บหร การพนน เชน โครงการโรงเรยนค าพอสอน / โครงการโพธสตวนอย- “ลกขอพอแมเลกเหลา” เปนตน





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ผลงานท 1

นน





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(หนาถดไปใหแทรกภาพประกอบ พรอมค าอธบาย ไมเกน 4 ภาพ)





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ผลงานท 2 (ถาม)

นน





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ผลงานท 3 (ถาม)

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10. ผรบรอง ตองครบ 3 คน (หากผรบรองไมครบ และคณสมบตไมตรงตามทก าหนดไวในค าชแจง ถอวาผสมครครดไมมอบายมข ปท 9 ขาดคณสมบต จะไมไดรบการพจารณา) เนองจากเหตผลของผรบรอง เปนขอมลทมผลตอการพจารณา

ผรบรองคนท 1 ขอรบรองวา (ชอ-สกล ผเสนอครดไมมอบายมข ปท 9).......................................................................................... เหตผลทใหการรบรองเพราะ………………………………………………….........………………………………………………………………………………..… ……………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………............................................................................. ..........................

ลงชอผรบรอง ........................................................ ..................... (................................................................................) ต าแหนง(ทตรงตามเงอนไข ครดไมมอบายมข)............................................ .............. วนท................../..................../...................... สถานทท างานของผรบรอง......................................................................................................... เบอรโทรศพท.................................


ลงชอผรบรอง .................................................................... ......... (................................................................................) ต าแหนง(ทตรงตามเงอนไข ครดไมมอบายมข)............................................ .............. วนท................../..................../...................... สถานทท างานของผรบรอง............................................................................... .......................... เบอรโทรศพท.................................


ลงชอผรบรอง .................................................................... ......... (................................................................................) ต าแหนง(ทตรงตามเงอนไข ครดไมมอบายมข)............................................ .............. วนท................../..................../...................... สถานทท างานของผรบรอง............................................................................... .......................... เบอรโทรศพท.................................





11. ขาพเจาขอตงสจอธษฐาน รบรองวา ขอมลทงหมดขางตน เปนความจรงทไดปฏบต โดยมไดคดลอกจากผใด หากคณะกรรมการตรวจสอบแลวพบวา การปฏบตตวของขาพเจาเปนความเทจ มการคดลอกหรอมขอมลอนอนเปนเทจ ขาพเจาขอสละสทธในการรบรางวล และถงแมไดรบหรอไมไดรบคดเลอกเปนครดไมมอบายมขกตาม ขอตงสจอธษฐานวาจะประพฤตปฏบตตน เปนครทด าเนนชวตปราศจากอบายมข 6 มศลธรรมของศาสนาค าจนจตวญญาณ และด าเนนชวตตามหลกปรชญาของเศรษฐกจพอเพยง เปนตวอยางทดแกศษยและจะชวยเหลอผอนใหพนภยจากอบายมข เครองดมแอลกอฮอลทกชนด บหร และการพนนทกรปแบบ สจอธษฐานทตองการเพมเตม ............................................................................................... ................................................... ................................................................................................................................ .................................................................... ....................

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ลงชอผสมคร ...................................................................

(..................................................................)

วนท.............../................../..................

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