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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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
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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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Rural
Urban
Suburban
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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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