Declaration Form for Using AI/Chatbot in Modular Distance Learning Activities
Student Information
Name: ______________________________________ Subject: _________________________
Grade Level and Section:_____________________ Date: ____________________________
Teacher's Name: ______________________________
Declaration
I, the undersigned student, declare that I have used an AI/Chatbot (e.g., Microsoft
Copilot, meta AI) to assist me in completing my modular distance learning activities. I
understand and agree to the following:
1. I have used the AI/Chatbot responsibly and ethically to seek information, clarify
concepts, or gain assistance in understanding my modules.
2. I have documented all the prompts I used during the process and listed them
below.
3. I am aware that the AI/Chatbot is a tool to aid my learning, and I have not relied
solely on it for completing my assignments without proper understanding.
4. I acknowledge that any misuse or inappropriate use of the AI/Chatbot will result in
disciplinary actions analogous to what is discussed per school policies.
Prompts Used:
No. Prompt Used
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
* (Add more rows as needed)
Student's Signature:_________________________Date: _________________
Teacher's Verification:
I, the undersigned teacher, verify that the above student has provided a complete list
of prompts used in their modular distance learning activities.
Teacher's Signature:___________________________
Date:________________________________________