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

Facility Name*

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Community name*

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Ward*

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LGA*

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State*

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Number of PWDs

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Name of Community Leader*

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Population of the community members*

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Location of facility*

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Section 2: Nomination Section
Must be completed

Has the project been nominated previously? YES or NO*

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If yes, when?

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Year of Nomination*

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

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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?

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Does your community have adequate sanitation facilities?

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How many toilets does the PHC in your community have?

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How many wards does the PHC in your community have?

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Is there a fence in the PHC?

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

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How many beds does the PHC in your community have?

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Is there an adequate potable water supply in your PHC?

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Is there a separate toilet for males and females in the PHC in your community?

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Is there a toilet for the staff of the PHC in your community?

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How many PHC buildings in your community need renovation?

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Is there drug availability in your PHC?

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Are there doctors' or health workers' quarters?

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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

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

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Phone number of the youth leader

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Phone number of the CoP Lead

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Phone number of the Head of Facilities

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Date of nomination

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Phone number of CoP rep

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Phone number of Community Leader

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Name of CoP Lead

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Name of Head of Facilities

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Name of Youth Leader

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

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

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