Project Nomination Form
Section 1, General Facility Data (must be completed)

Facility Name*

Facility Name*

Clear selection

Community name*

Community name*

Clear selection

Ward*

Ward*

Clear selection

LGA*

LGA*

Clear selection

State*

State*

Clear selection

Location of facility*

Location of facility*

Clear selection

Population of the community*

Population of the community*

Clear selection

Name of Community Leader*

Name of Community Leader*

Clear selection

Number of PWDs

Number of PWDs

Clear selection
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Section 2: Nomination Section
Must be completed

What project in your community do you want MDAs or legislators to include in the next State Budget/ZIP*

What project in your community do you want MDAs or legislators to include in the next State Budget/ZIP*

Clear selection

Year of Nomination*

Year of Nomination*

Clear selection

Has the project been nominated previously? YES or NO*

Has the project been nominated previously? YES or NO*

Clear selection

If yes, when?

If yes, when?

Clear selection
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Section 3: Other relevant facility data
Complete each question on each annual submission

Does your community have an adequate potable water supply?

Does your community have an adequate potable water supply?

Clear selection

Does your community have adequate sanitation facilities?

Does your community have adequate sanitation facilities?

Clear selection

How many toilets does the school in your community have?

How many toilets does the school in your community have?

Clear selection

How many classroom blocks does the school in your community have?*

How many classroom blocks does the school in your community have?*

Clear selection

Is there a fence in your school?*

Is there a fence in your school?*

Clear selection

Is the structure of the school accessible to PWDs (e.g ramps and wide doors)

Is the structure of the school accessible to PWDs (e.g ramps and wide doors)

Clear selection

Is there an adequate potable water supply in your School?

Is there an adequate potable water supply in your School?

Clear selection

Are there teachers' quarters?

Are there teachers' quarters?

Clear selection
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Section 4: Details of Information Provider/Nominator
The form must be completed by the Community Leaders/ CMT Leads in the community

Name of Community Leader (Traditional, Religious, Political, etc)

Name of Community Leader (Traditional, Religious, Political, etc)

Clear selection

Name of Women Leader (Traditional, Religious Political, WDC and SBMC etc)

Name of Women Leader (Traditional, Religious Political, WDC and SBMC etc)

Clear selection

Name of Youth Leader

Name of Youth Leader

Clear selection

Name of Head of Facilities

Name of Head of Facilities

Clear selection

Name of CoP Lead

Name of CoP Lead

Clear selection

Phone of Community Leader

Phone of Community Leader

Clear selection

Phone of CoP rep

Phone of CoP rep

Clear selection

Date

Date

Clear selection

Phone of Women Leader (Traditional, Religious Political, WDC and SBMC etc)

Phone of Women Leader (Traditional, Religious Political, WDC and SBMC etc)

Clear selection

Phone number of the youth leader

Phone number of the youth leader

Clear selection

Phone number of the Head of Facilities

Phone number of the Head of Facilities

Clear selection

Phone number of the CoP Lead

Phone number of the CoP Lead

Clear selection
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