Facility Name^*

Community name^*

Ward^*

LGA^*

State^*

Number of PWDs

Name of Community Leader^*

Population of the community members^*

Location of facility^*

Has the project been nominated previously? YES or NO^*

If yes, when?

Year of Nomination^*

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

Does your community have an adequate potable water supply?

Does your community have adequate sanitation facilities?

How many toilets does the PHC in your community have?

How many wards does the PHC in your community have?

Is there a fence in the PHC?

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

How many beds does the PHC in your community have?

Is there an adequate potable water supply in your PHC?

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

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

How many PHC buildings in your community need renovation?

Is there drug availability in your PHC?

Are there doctors' or health workers' quarters?

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

Phone number of the youth leader

Phone number of the CoP Lead

Phone number of the Head of Facilities

Date of nomination

Phone number of CoP rep

Phone number of Community Leader

Name of CoP Lead

Name of Head of Facilities

Name of Youth Leader

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

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