Manual on Community Based Approach to Local Development Project – Phase 2 (стр. 27 )

VC/CC Level Information Collection

Village/City Council: Rayon: Oblast:

S. N.	Name of settlement/ micro-rayon	HHs	Population	Distance from rayon centre (km)	% of low income families
	1	2	3	4	5
1
2

S. N.	Water management
cold water supply system	hot water supply system	Need for micro-irrigation	Other
exists	Does not exist	needs improvement	exists	Does not exist	needs improvement
please, comment
	6	7	8	9	10	11	12	13
1
2

S. N.	Health post
doesn’t exist	exist but not functional	function satisfactory
	14	15	16
1
2

S. N.	Environmental situation
sanitation problem	drainage sewerage	solid waste problem	radioactivity zone	other
H[i]	M	L	H	M	L	H	M	L	H	M	L
	17	18	19	20	21	22	23	24	25	26	27	28	29
1
2

Note: H = High degree; M = Medium level; L = Low level

S. N.	Energy saving
Energy loss problem - comment	access to gas supply	Heating system	other
Doesn’t exist	Exists but not functioning	Functioning well	Doesn’t exist	Exists but not functioning	Functioning well
	30	31	32	33	34	35	36	37
1
2

Annex - 7

Application For Village/City Council To Join CBA-II

PART – A: EXPLANATORY NOTE

·  This form is applicable for only those village/city councils which belong to the rayon already selected for partnership with the Project

·  Only those village/city councils which have population 10,000 or less will be eligible for partnership with CBA-II. Village/city councils with more than 10,000 population should not apply

·  Completed Application Form (Part-B) should be attached with a letter signed by head of village/city council and sent to the Regional Implementation Unit of CBA Project located in the oblast state administration/oblast council office

B) APPLICATION FORM

1. APPLICANT’S PROFILE

Oblast
Rayon
Village/City Council
Postal Address
Telephone (dialling code + number)
Fax (dialling code + number)
Focal Point
Position
Telephone (dialling code + number)
Previous Partnership	(Give period of partnership with CBA-I)

2)  TERRITORIAL PROFILE

§  Provide general information about the village/city council including:

-  Number of population;

-  Distance between rayon capital and village/city council

§  Provide brief description of existing social, economic, environmental problems and access to public services in the village/city council in terms of:

A.  Level of socio-economic development

o  Rayon’s ranking of the village/city councils based on practical set of social and economic indicators followed in the rayon to rank all village/city councils)

o  Availability of development budget per year

o  Level of unemployment

B.  Access to water supply (mark one)

Number of settlements/micro-rayons in the village/city council

Percentage of settlements/micro-rayons and households therein that:

o  have a water supply system

o  have a water supply system in disrepair

o  have access to well water only

o  have no access to drinking water

C.  Quality of healthcare infrastructure (mark one)

o  The village/city council has good local healthpost/outpatient’s clinic

o  The local healthpost / local outpatient’s clinics in disrepair

o  The village/city council has no health-care infrastructure or the one exists is non-functional

D.  Environment

o  Status of solid waste collection and utilization system by settlements/micro-rayon

o  Status of sewerage and sanitation system by settlements/micro-rayon

o  Point some factors that negatively affects environmental situation in the village/city council

E.  Energy efficiency

o  Situation of current energy supply infrastructure and energy consumption (in terms of gas, electricity etc.)

o  Practice of introducing energy saving technologies in the village/city council

o  Point if there is potential to introduce energy saving technologies (involving alternative and/or renewable energy sources) in remote communities of the village/city council

3. MOTIVATION TO PARTICIPATE IN THE PROJECT

3.1. Reasons of your interest to the CBA Project

3.2. Expectations from participation in the CBA Project

3.3. Experience in the use of community based approach (if any)

3.4. Participation in similar projects/ programmes (name of the project, data, donor, cost)

3.5. Other respective information

4. WILLINGNESS TO MEET OBLIGATIONS IN FRAMES OF THE CBA PROJECT

4.1. Deputing an official to support the project realization

4.2. Allocation of resources to realize community projects (write approximate sum)

4.3. Incorporation of community plans to local development plans

4.4. Providing organizational, monitoring and technical services

4.5. Providing institutional mechanism for sustainability of community project

4.6. Allocating premises for establishment of community resource centre (if possible)