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

Facility Name*

Clear selection

Community name*

Clear selection

Ward*

Clear selection

LGA*

Clear selection

State*

Choose
Abuja
Abia
Adamawa
Akwa Ibom
Anambra
Bauchi
Bayelsa
Benue
Borno
Cross River
Delta
Ebonyi
Edo
Ekiti
Enugu
Gombe
Imo
Jigawa
Kaduna
Kano
Katsina
Kebbi
Kogi
Kwara
Lagos
Nasarawa
Niger
Ogun
Ondo
Osun
Oyo
Plateau
Rivers
Sokoto
Taraba
Yobe
Zamfara
Clear selection

Location of facility*

Choose
Rural
Urban
Suburban
Clear selection

Population of the community*

Clear selection

Name of Community Leader*

Clear selection

Number of PWDs

Clear selection
Page 1 of 4
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*

Clear selection

Year of Nomination*

Clear selection

Has the project been nominated previously? YES or NO*

Clear selection

If yes, when?

Clear selection
Page 1 of 4
Section 3: Other relevant facility data
Complete each question on each annual submission

Does your community have an adequate potable water supply?

Clear selection

Does your community have adequate sanitation facilities?

Clear selection

How many toilets does the school in your community have?

Clear selection

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

Clear selection

Is there a fence in your school?

Clear selection

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?

Clear selection

Are there teachers' quarters?

Clear selection
Page 1 of 4
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)

Clear selection

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

Clear selection

Name of Youth Leader

Clear selection

Name of Head of Facilities

Clear selection

Name of CoP Lead

Clear selection

Phone of Community Leader

Clear selection

Phone of CoP rep

Clear selection

Date

Clear selection

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

Clear selection

Phone number of the youth leader

Clear selection

Phone number of the Head of Facilities

Clear selection

Phone number of the CoP Lead

Clear selection
Page 1 of 4