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
2. Internal activities
3. Education and skills
development
Technical
4. Policies, systems and
procedures
Financial
5. Financial contribution
6. Financial transactions
Reputation and
acceptability to the
community and other
groups
7. Involvement to other
activities
8. Affiliations
Certificate of registration
Minutes of meetings
Copies of board resolutions
Certificates oftrainings
andseminars attended
Internal policy on project
implementation, monitoring
and evaluation
CBU records
Financial reports
Certificate of good standing
from agency/s, LGU or head
of a religious organization
Certificate of membership

Recommendation:
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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