Pre-Evaluation Report Form

Republic of the Philippines
DEPARTMENT OF AGRICULTURE
Caraga Region
Agricultural Program Coordinating Office
Province of Agusan del Norte
PRE-EVALUATION REPORT
Name of Proponent : _____________________________________________________________________
_____________________________________________________________________
Address : _____________________________________________________________________
Contact Person : _____________________________________________________________________
Contact Number : _____________________________________________________________________
Type of Assistance Requested (please specify):
( ) Production inputs _____________________ ( ) Livestock/Poultry_________________
( ) Pre harvest _____________________ ( ) Post harvest_________________
( ) Irrigation _____________________ ( )Others_________________
Organizational Profile:
Type of Organization: ( ) Coop() Association( ) Others (specify)____________

No. of Members : Non-IP _____ Male _____ Female ______ Total
IP _____ Male _____ Female ______ Total
Accrediting Agency : ( ) CDA ( ) SEC ( ) DOLE( ) Others __________________
Registration No. : _________________________ Date of Registration : __________________
Programs and projects previously implemented or currently being implemented:
Cost of Fund Year

Name of Project Status
Project (P) Source Implemented
No. of years in farming : ____________________ Type of land ownership_________________

Agricultural commodities : 1___________________ 2______________________ 3___________________
Area devoted (hectares ) : 1___________________ 2______________________ 3___________________
Average production (MT) : 1___________________ 2______________________ 3___________________
Market outlets : 1___________________ 2______________________ 3___________________
Remarks: _________________________________________________________________________________________
_____________________________________________________________________________________________________
Problems to be addressed by the intervention:

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
1
Other considerations:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Willingness to provide counterpart in cash or in kind : ( ) Yes ( ) No

Remarks: _________________________________________________________________________________________
Willingnessto allocate funds for operation and maintenance : ( ) Yes ( ) No

Remarks: _________________________________________________________________________________________
Availability of power supply ( ) Yes ( ) No

Remarks: _________________________________________________________________________________________
Availability of water supply ( ) Yes ( ) No

Remarks: _________________________________________________________________________________________
Road network connection( ) Barangay( ) Municipal( ) Provincial( ) National

Road condition ( ) Very Good( ) Good ( ) Fair ( ) Bad
Remarks: _________________________________________________________________________________________
Other findings:
Aspect Supporting Documents Yes No Remarks

Organizational
1. Legal personality Certificate of registration
2. Internal activities Minutes of meetings
Copies of board resolutions
3. Education and skills Certificates oftrainings
development andseminars attended
Technical
4. Policies, systems and Internal policy on project
procedures implementation, monitoring
and evaluation
Financial
5. Financial contribution CBU records
6. Financial transactions Financial reports
Reputation and
acceptability to the
community and other
groups
7. Involvement to other Certificate of good standing
activities from agency/s, LGU or head
of a religious organization
8. Affiliations Certificate of membership
Recommendation:
2
For endorsement to DA-Regional Office Date: ____________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Return to proponent due to: Date: ____________________________

( ) Ineligibility
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
( ) Additional requirements
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
( ) Others (please specify)

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Name of Interviewee : ________________________________________________

Position : ________________________________________________
Contact Number : ________________________________________________
Date of Evaluation : ________________________________________________
Name of Evaluator : ________________________________________________

Position : ________________________________________________
MAO Representative : ________________________________________________

Position : ________________________________________________
Noted:
EDELMIRA R. LUMINARIAS
OIC, APCO-Agusan del Norte

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Republic of the Philippines

Type of Organization: ( ) Coop() Association( ) Others (specify)____________

Programs and projects previously implemented or currently being implemented:

Cost of Fund Year

No. of years in farming : ____ Type of land ownership_

Problems to be addressed by the intervention:

Willingness to provide counterpart in cash or in kind : ( ) Yes ( ) No

Willingnessto allocate funds for operation and maintenance : ( ) Yes ( ) No

Availability of power supply ( ) Yes ( ) No

Availability of water supply ( ) Yes ( ) No

Road network connection( ) Barangay( ) Municipal( ) Provincial( ) National

Aspect Supporting Documents Yes No Remarks

Return to proponent due to: Date: ____________________________

( ) Others (please specify)

Name of Interviewee : ________________________________________________

Name of Evaluator : ________________________________________________

MAO Representative : ________________________________________________

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