Department of the Interior and Local Government Form P 3.

1
Assessment for the Seal of Good Local Governance Financial Administration
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form P 3.1 Financial Administration

Province of : __________________________________ Income Class :

Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the LGOO from the Province and onsite visit, please supply the required
information or tick applicable LGU condition under Column A. (2) For data provided by partner agencies –items marked with (N)- indicate
whether there is a discrepancy as compared to LGU data. Pending data reconciliation, RAT may carry the answer that favors the LGU. (3)
In case of a correction/erasure, RAT leader must affix signature parallel to corrected portion. (4) AFFIX SIGNATURE AT THE END OF EACH
ASSESSMENT AREA, and PUT INITIALS AT THE BOTTOM OF EACH PAGE. ONLY DULY ACCOMPLISHED FORMS ARE TO BE ENCODED BY THE RFP.

Column A Column B
Required Data Processing of
results
1(N) The LGU’s audit opinion, as rendered by the Commission on Audit: Most recent audit
Kindly tick the audit opinion given based on respective year’s AAR. opinion is
un/qualified plus
2017 ☐ Unqualified ☐ No Opinion 30% of
☐ Qualified ☐ No Annual Audit Report recommendations
fully acted upon?
☐ Disclaimer
☐ Yes
☐ Adverse ☐ No
Percent of fully-complied with recommendations: ________ %
2018 ☐ Unqualified ☐ No Opinion
☐ Qualified ☐ No Annual Audit Report
☐ Disclaimer ☐ Not yet available
☐ Adverse
Percent of fully-complied with recommendations: ________ %
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy
2 The LGU fully complied with posting in: FDP compliant?
☐ (N) Full Disclosure Policy Portal for CY 2018 all quarters, and CY 2019 1st Quarter ☐ Yes
posting period documents ☐ No
☐ (N) e-SRE portal for 2017 e-Statement of Receipts and Expenditures
☐ Three (3) conspicuous places for CY 2018 all quarters, and CY 2019 1st Quarter
posting period documents (based on accomplished Form CM 2E: DILG Field Office)

LGU-NGA Data Discrepancy Check (tick as appropriate):

☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

3(N) Average local revenue growth of LGU from CYs 2015 to 2017 is (based on accomplished At least 5%?
Form P 2K: Treasurer’s Office): % ☐ Yes
☐ No
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

1
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
4a The Local Development Council: LDC: (i) complied
Total no. of the fully organized Council: ________ with prescribed
No. of NGO representatives as council members: ________ composition, (ii)
has an executive
Composition ☐ Constituted according to Sec. 107 of the LG Code committee, (iii)
met at least once
☐ Not constituted per Sec. 107
for 2 sems, (iv) has
Executive ☐ Present all plans, and (v)
committee ☐ None has secretariat?
NGO composition ☐ More than ¼ of the fully organized LDC ☐ Yes
in LDC ☐ ¼ of the fully organized LDC ☐ No
☐ Less than ¼ of the fully organized LDC.
NGO composition In case NGO composition is less than ¼:
is less than ¼ due ☐ Insufficient number of organized CSOs in the locality
to: ☐ Organized, but insufficient number of accredited CSOs in
the locality
☐ Others. Please specify:
______________________________________
Meetings ☐ Met at least once between CY 2018 January to June
☐ Met at least once between CY 2018 July and December
Plans ☐ Approved PDPFP
Date approved: __________________
Period covered: __________________
☐ Has a Local Development Investment Program
☐ Has CY 2019 Annual Investment Plan

☐ Created sectoral or functional committees (tick all present committees)

☐ Social development ☐ Environmental management
☐ Economic development ☐ Institutional development
☐ Physical/ land use/ ☐ Others. Please specify:
infrastructure ______________________________________
development
☐ Has a Secretariat which provides technical assistance, documentation of
proceedings, and preparation of reports
☐ Said Secretariat tapped assistance of NGOs, academe and/or research
institutions
4b LDC members from NGO/CSO sector demonstrated participation in: NGO/CSO reps
☐ Attendance to LDC meetings attended one
☐ Submitted a CSO Plan of Action; date received by LDC: _____________________ meeting each
sem, AND their
☐ Provided inputs during LDC meetings inputs captured in
Attended Inputs provided Minutes or has
& captured submitted Plan
Between CY 2018 January and June ☐ ☐ ☐ Yes
Between CY 2018 July and December ☐ ☐ ☐ No

5(N) 20% component of CY 2017 Internal Revenue Allotment (Development Fund; DF) Appropriated at
least 20% of IRA as
5.1 Appropriation (based on accomplished Form P 2K: Treasurer’s Office) LDF?
☐ Yes
Total amount of 2017 IRA : PhP ____________________
☐ No
Amount allocated as DF : PhP ____________________
-AND-
In percent : ______ %

2
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
5.2 Fund utilization (based on accomplished Form P 2K: Treasurer’s Office) Full utilization, or
Utilized amount out of DF : PhP ____________________ [CONSIDERATION] met
benchmark at
In percent (LDF utilized/20% of
least?
IRA) x 100 : ______ %
☐ Yes
☐ No
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

6(N) The LGU is a beneficiary of Performance Challenge Fund, and PCF-beneficiary?

☐ Yes
Fund utilization is (based on accomplished Form P 2A: Accountant’s Office; put N/A for not ☐ No
applicable items)
CY 2016 CY 2017 If yes, full utilization
Total amount PhP ____________________ PhP ___________________ of all PCF?
Amount utilized PhP ____________________ PhP ___________________ ☐ Yes
☐ No
Percent-utilization is ______ % ______ %
Not applicable ☐ ☐

LGU-NGA Data Discrepancy Check (tick as appropriate):

☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

7 The LGU’s Annual Budget is: Budget approved

☐ Approved; date of approval: _______________________ by Dec. 31, 2018,
☐ Re-enacted or [CONSIDERATION]
approved not later
than Mar. 31,
2019?
☐ Yes
☐ No

[END OF FINANCIAL ADMINISTRATION]

CERTIFICATION
We hereby certify that all information contained in this assessment report are true and correct, and are
correspondingly supported by documents and other means of verifications as reviewed by the undersigned.

Date: _________________________________
1. RAT Leader
_______________________________________________ ______________________________
Signature over Printed Name (1) DILG-Place of Assignment

2. Partner-CSO rep
_______________________________________________ ______________________________
(2) Signature over Printed Name (2) Name of Organization
3. Partner-NGA rep
_______________________________________________ ______________________________
(3) Signature over Printed Name (3) Name of Agency
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

3
 Department of the Interior and Local Government Form P 3.2
Assessment for the Seal of Good Local Governance Disaster Preparedness
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form P 3.2 Disaster Preparedness

Province of : __________________________________ Income Class :

Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the LGOO from the Province and onsite visit, please supply the required
information or tick applicable LGU condition under Column A. (2) For data provided by partner agencies –items marked with (N)- indicate
whether there is a discrepancy as compared to LGU data. Pending data reconciliation, RAT may carry the answer that favors the LGU. (3)
In case of a correction/erasure, RAT leader must affix signature parallel to corrected portion. (4) AFFIX SIGNATURE AT THE END OF EACH
ASSESSMENT AREA, and PUT INITIALS AT THE BOTTOM OF EACH PAGE. ONLY DULY ACCOMPLISHED FORMS ARE TO BE ENCODED BY THE RFP.

Column A Column B
Required Data Processing of
results
1(N) The LGU is 1st place in the 2018 National Gawad KALASAG Awardee for Best Gawad KALASAG
LDRRMCs or Hall of Fame Awardee (2015 onwards). Awardee?
☐ Yes ☐ Yes
☐ No
☐ No

LGU-NGA Data Discrepancy Check (tick as appropriate): If not an awardee,

must meet items #2
☐ Data differ; included in the accomplished Change Request Form
to #12
☐ No data discrepancy

LGU Hazard Profile: Please rank the risk level of the following hazards according to LGU’s
response. Put “1” for the hazard that presents highest risk, then “6” for the hazard with the
lowest risk.

_____ Earthquake/ Ground-shaking potential

_____ Flood
_____ Rain-induced landslide
_____ Storm surge
_____ Typhoon
_____ Other hazards. Please specify: _______________________

2 The LGU has a Local Disaster Risk Reduction and Management Council: Met condition on
Council
2.1 Composition: composition and
meetings?
☐ At least four (4) accredited CSO representatives
☐ Yes
☐ At least one (1) private sector representative
☐ No

2.2 Meetings:
☐ Met at least once in CY 2018 1st quarter
☐ Met at least once in CY 2018 2nd quarter
☐ Met at least once in CY 2018 3rd quarter
☐ Met at least once in CY 2018 4th quarter

4
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
3 The Local Disaster Risk Reduction and Management Office: LDRRMO head
occupies plantilla
3a Is headed by: position with the
prescribed SG and
Position title : ____________________________________________
with a CSC-
Salary grade : SG - ______ attested
Date of appointment?
appointment : _______________________________ ☐ Yes
Nature of ☐ Permanent ☐ No
appointment : ☐ Temporary
[CONSIDERATION]
Status of CSC : ☐ With affixed signature of CSC Field Office If no, LDRRMO
attestation representative appointment falls
☐ LGU is CSC-accredited to take final actions in identified
on appointments consideration
☐ Copy of appointment endorsed to CSC cases in
Field Office for attestation technotes?
☐ Yes
Date endorsed: ____________________________
☐ No

-AND-

Has the prescribed

3b Has LDRRMO staff complement: no. of plantilla
LDRRMO staff?
No. of plantilla staff :
☐ Yes
complement __________ ☐ No
No. of designated staff :
complement __________ [CONSIDERATION]
If no, has
prescribed no. of
designated staff
complement?
☐ Yes
☐ No

NOTE: This item to be jointly verified with DRR-CCA Focal Person PDPFP approved?
4 The LGU has a Provincial Development & Physical Framework Plan (PDPFP) that is: ☐ Yes
☐ No
☐ (N) Approved; period covered is _________ to _________
[CONSIDERATION]
☐ Not yet approved
If no, draft PDPFP is
Latest duly approved Plan : under review and
period of effectivity ________________________________ contains risk
Status : ☐ Under review of NEDA assessment results?
☐ Currently revising ☐ Yes
☐ Currently drafting ☐ No
Draft PDPFP : ☐ Period covered is: _________ - _________
☐ Already contains results of risk
assessment
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

NOTE: This item to be jointly verified with DRR-CCA Focal Person LDRRM Plan met
5 The LDRRM Plan of the LGU: two conditions?
☐ Incorporates hazard, vulnerability and risk assessment data ☐ Yes
☐ Budget is integrated in the 2019 Annual Investment Program (based on ☐ No
accomplished Form P 2C)

5
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
NOTE: This item to be jointly verified with DRR-CCA Focal Person LCCAP met two
6 The LGU has a local climate change action plan (LCCAP) that is (please tick one item only): conditions in 6.1?
☐ Separate or stand-alone; approved on: ___________________ ☐ Yes
☐ Integrated in the approved PDPFP ☐ No

6.1 LCCAP contains information on:

☐ Results of risk assessment
☐ Climate change adaptation and mitigation actions

NOTE: This item to be jointly verified with DRR-CCA Focal Person Valid Contingency
7 The LGU has a contingency plan for (please refer to LGU Hazard Profile in Page 5): Plan for top 2 high-
risk hazards that is
☐ Top 1 Hazard; Indicate here: _______________________ approved and
☐ Top 2 Hazard; Indicate here: _______________________ satisfied all Plan
inclusions?
☐ Yes
Top 1 Hazard Top 2 Hazard ☐ No
Plan is approved ☐ ☐
- Date approved: _____________ _____________
Plan includes:
- Anatomy of the hazard ☐ ☐
- Scenario generation ☐ ☐
- Affected population ☐ ☐
- Coordination, command and control ☐ ☐
protocols
- Activation, deactivation and non- ☐ ☐
activation protocols

8 Local Disaster Risk Reduction and Management Fund for CY 2018 LDRRMF allocation
is equal to or
8.1 Source of Fund (based on accomplished Form P 2A: Accountant’s Office) greater than 5% of
revenue from
Estimated revenue from
regular sources?
regular sources : PhP ____________________ ☐ Yes
Amount allocated as ☐ No
LDRRMF in CY 2018 : PhP ____________________
-AND-
In percent : ______ %
At least 50% of the
8.2 Fund utilization of 70% component of CY 2017 LDRRMF (based on accomplished 70% component of
Form P 2A: Accountant’s Office) LDRRMF utilized?
Total amount of 70% ☐ Yes
component : PhP ____________________ ☐ No

Amount utilized : PhP ____________________

In percent : ______ %

9 The LGU has an early warning system (EWS) which includes (based on accomplished Form P 2E: EWS present (9a,
DILG Field Office): 9b, 9c, and either
Present None in 9c)?
☐ Yes
9a At least one (1) marker present in high risk area of:
☐ No
- Top 1 hazard ☐ ☐
- Top 2 hazard ☐ ☐
9b Warning and alarm system is audible and wide-ranging ☐ ☐

6
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
9c Available equipment is:
- Automated rain gauge ☐ ☐
-Locally-innovated technology ☐ ☐
9d Info on EWS present in conspicuous places ☐ ☐

10a Evacuation management – Evacuation center (EC) Has an identified

EC with all
Indicate name of identified minimum required
evacuation center (one center only) ________________________________________ facilities present?
Location ________________________________________ ☐ Yes
☐ Permanent ☐ No
Status of identified EC
☐ Semi-permanent
-AND-
☐ Temporary (in partnership with a
school/ child-development centers) Has system for
Facilities present in identified EC Minimum requirements: registration and
(tick all available facilities) ☐ Kitchen area satisfied all
☐ Water supply conditions for
posted info guide?
☐ Communication means
☐ Yes
☐ Toilet and bath facilities ☐ No
☐ Waste disposal system

Other functional requirement:

☐ Health service station
☐ Power supply with back-up system
☐ Administrative office

Socially-inclusive facilities:
☐ Breastfeeding station
☐ Couples’ room
☐ Child-friendly learning space
☐ Ramps or other assistive device for
PWDs and elderly
System for registration ☐ Present
☐ Not available
Posted information guide ☐ Written in local dialect
☐ Shows facilities and services
☐ Has map
10b Evacuation management – Prepositioned goods and resources Has partnership w/
volunteer groups,
Mobilization and management of ☐ Present plus mechanisms
for: relief goods,
volunteer groups ☐ None
medical services,
Goods for relief operations ☐ Stockpiling including: _________ food packs psycho-social
and ______ hygiene kits support, and
☐ Partnership with suppliers (e.g. security services?
supermarket, pharmacy) ☐ Yes
☐ None ☐ No
Medical services after a disaster ☐ In-house (LGU’s own medical service)
☐ Partnership with other government
(national/local) medical service
☐ Partnership with private/ NGO entities
Pyscho-social support as life ☐ In-house (LGU’s own medical service)
coaching, stress debriefing, ☐ Partnership with other government
(national/local) service

7
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
comforting and processing after ☐ Partnership with private/ NGO entities
the disaster

System to ensure peace and order ☐ Present

and security in the event of ☐ None
disasters

11 Standard Operating Procedures are available. Has SOP?

☐ Yes ☐ Yes
☐ No ☐ No

11a SOP – LDRRM Operations Center Has permanent

OpCen?
The LGU has an LDRRM OpCen that is: ☐ Yes
☐ Permanent (functions 24/7 daily) ☐ No
☐ Temporary (functions 24/7 during disasters)

11b SOP– Trained and equipped SAR or ER teams Organized w/in

last three years?
11b1 Organized and trained ☐ Yes
☐ No
SAR/ER Teams: Yes No
Organized within the last three years ☐ ☐
-AND-
Trained (w/in last three years) relative to:
- Top 1 Hazard ☐ ☐ Trained for top 1
- Top 2 Hazard ☐ ☐ and 2 hazards?
☐ Yes
11b2 Equipped with: ☐ No
Yes No
-AND-
Motorized vehicle ☐ ☐
Generator set Has all the
Water rescue kit (at the minimum: rope, life ☐ ☐ enumerated
jacket, flotation ring or alternate) equipment?
Extrication kit (at the minimum: spine board, ☐ ☐ ☐ Yes
shovel or alternate digging device) ☐ No
Personal protective equipment (at the ☐ ☐
minimum: helmet, goggles, work gloves, boots)
First aid kit ☐ ☐
Emergency medical kit ☐ ☐

11c SOP – Incident Command System (ICS) Has EO for ICS + at

least 1 LDRRMC
12c1 The LGU has an ICS that is contained in an executive order or similar issuance. head/ member or
LDRRMO
☐ Yes
head/staff
☐ No Trained in ICS?
☐ Yes
12c2 Trained in ICS ☐ No
ICS Training No. of LDRRMC No. of LDRRMO
Level head/ member member trained
trained
I _______ _______
II _______ _______
III _______ _______
IV _______ _______

8
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
12d SOP – For pre-emptive and forced evacuation Met this condition?
☐ Yes
The LGU has an SOP for pre-emptive and forced evacuation: ☐ No
☐ Yes
☐ No

[END OF DISASTER PREPAREDNESS]

CERTIFICATION
We hereby certify that all information contained in this assessment report are true and correct, and are
correspondingly supported by documents and other means of verifications as reviewed by the undersigned.

Date: _________________________________
1. RAT Leader

_______________________________________________ ______________________________
Signature over Printed Name (1) DILG-Place of Assignment
2. Partner-CSO rep

_______________________________________________ ______________________________
(2) Signature over Printed Name (2) Name of Organization
3. Partner-NGA rep
______________________________
_______________________________________________ (3) Name of Agency
(3) Signature over Printed Name
4. DRR-CCA Focal Person

_______________________________________________ ______________________________
(4) Signature over Printed Name (4) DILG-Place of Assignment
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

9
 Department of the Interior and Local Government Form P 3.3
Assessment for the Seal of Good Local Governance Social Protection
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form P 3.3 Social Protection

Province of : __________________________________ Income Class :

Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the LGOO from the Province and onsite visit, please supply the required
information or tick applicable LGU condition under Column A. (2) For data provided by partner agencies –items marked with (N)- indicate
whether there is a discrepancy as compared to LGU data. Pending data reconciliation, RAT may carry the answer that favors the LGU. (3)
In case of a correction/erasure, RAT leader must affix signature parallel to corrected portion. (4) AFFIX SIGNATURE AT THE END OF EACH
ASSESSMENT AREA, and PUT INITIALS AT THE BOTTOM OF EACH PAGE. ONLY DULY ACCOMPLISHED FORMS ARE TO BE ENCODED BY THE RFP.

Column A Column B
Required Data Processing of
results
1 The 2018 Local School Board Plan attained a completion rate in PPAs or fund utilization Achieved at least
85% completion or
of (based on Form P 2D: Dep Ed Representative): _______%
utilization rate?
☐ Yes
1.1 The Plan completed, or fund was utilized for, the following items (tick appropriate
☐ No
items):
☐ Operation and maintenance of public schools
☐ Construction and repair of school buildings
☐ Facilities and equipment
☐ Educational research
☐ Purchase of books and periodicals
☐ Sports development
☐ Others. Please specify: ______________________________________

2a The following mechanism in support of gender and development is present: Has items 2a1 to 2a3,
and code is updated
not earlier than CY
☐ 2a1 GAD Focal point system 2014, or
☐ 2a2 GAD database ([CONSIDERATION]
☐ 2a3 CY 2018 GAD accomplishment report updated not earlier
than CY 2009)?

2a4 GAD Code ☐ Yes

☐ Provincial code; year adopted: ___________ ☐ No
☐ Passed ordinance(s) amending/revising existing Code in year: -AND-
___________
Guideline-compliant
Plan and Budget, or
2a5 CY 2019 GAD Plan and Budget ([CONSIDERATION]
☐ Reviewed and was found fully compliant in form and content per submitted for review)
PCW-DILG-DBM-NEDA JMC No. 2016-01 (based on accomplished Form P 2E: at least?
DILG Field Office) ☐ Yes
☐ No
☐ Submitted at least to DILG officer for review

3 The LGU has a Code for Children: Has Code that is

updated not earlier
☐ Separate Provincial Code for Children; year adopted: ___________
than 2014, or
☐ Integrated in another Code; year adopted: ___________ [CONSIDERATION] not
☐ Passed ordinance(s) amending/revising existing Code in year: ___________ earlier than CY 2009
at least?
☐ No Code for Children
☐ Yes
☐ No

10
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
4 Philhealth-accreditation of hospital(s): At least 50% facilities
accredited in 2018 or
2019?
(a) Total No. of LGU-run hospitals _________ ☐ Yes
☐ No
CY 2019 CY 2018
accredited accredited
(b) Accreditation-level
Level I ______ ______
Level II ______ ______
Level III ______ ______
(c)Total of 2018/2019 accredited hospitals : ______
In % ______
To compute: ((c) / (a)) x100

LGU-NGA Data Discrepancy Check (tick as appropriate):

☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

5a The following physical feature or condition is present to enable mobility of persons with To pass: Met both
conditions under (i);
disability(based on accomplished Form P 2E: DILG Field Office):
met both conditions
under (ii); falls under
5a.1 Entrance/exit of LG building (iii) (iv) (v); OR
Physical feature/condition Capitol Main hospital [CONSIDERATION] met

(i) Has ramps: both conditions

under (v);
- That passed the Gradient Finder test ☐ ☐
[CONSIDERATION] met
- With 2-level handrail both sides ☐ ☐ both conditions
(ii) Has ramps adjacent to a wall: under (vi)
- Width is less than 1.20m ☐ ☐
- Two-level handrail in one side ☐ ☐ For capitol: Any of
above-enumerated
(ii) Ground level entrance or exit ☐ ☐ parameter?
(iii) Dropped curb ☐ ☐ ☐ Yes
(iv) With special lift or elevator at the ground level ☐ ☐ ☐ No
(v) LG building is a historical site
-AND-
- Certified by NHIP ☐ ☐
- Has facility/building catering to all PWD-related ☐ ☐ For main hospital:
concerns/services Any of above-
(vi) LG building is under construction enumerated
- Has facility/building catering to all PWD-related ☐ ☐ parameter met?
concerns/services ☐ Yes
- Construction plans include provision of ramps ☐ ☐ ☐ No
with 2-level handrails
5a.2 Toilet for PWDs To pass: Met
Physical feature/condition City/Mun Main hospital/ conditions (ii) (iii) (iv),
plus condition (vi) if
Hall health center
PWD toilet is located
(i) Located in: in upper floor; OR
- Ground floor ☐ ☐ [CONSIDERATION] met
- Upper floor ☐ ☐ condition under (v)
(ii) With prescribed grab bars ☐ ☐ Both capitol and
(iii) Door is wheelchair-accessible ☐ ☐ main hospital: Met
(iv) Has turning space ☐ ☐ required parameters
(v) LG building is under construction or met consideration
at least?
- Construction plans include provision of toilet for ☐ ☐
☐ Yes
PWD ☐ No
(vi) In case PWD toilet is located in upper floor, with ☐ ☐
special lift or elevator at the ground level
(vii) No toilet for PWDs ☐ ☐

11
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
5b The LGU has an entity that leads program/project/activity for PWDs: Has established
office and met all
conditions in
5b1 Persons with Disability Affairs Office recruitment process
☐ Established office through an ordinance of PDAO head?
☐ Established office through an executive order ☐ Yes
☐ No
☐ Appointed PDAO Head who is PWD
☐ Appointed PDAO Head who is not PWD Or: [CONSIDERATION] If
Details of appointment no, has a PDA focal
person?
Date of ☐ Yes
appointment : _____________________________ ☐ No
Nature of ☐ Permanent
appointment : ☐ Temporary
Status of CSC : ☐ With affixed signature of CSC Field Office
attestation representative
☐ LGU is CSC-accredited to take final actions
on appointments
☐ Copy of appointment endorsed to CSC
Field Office for attestation
Date endorsed: ______________________

5b2 Recruitment process for appointed PDAO Head

☐ General assembly (GA) with the PWD sector was held
☐ GA nominated at least 3 qualified applicants
☐ Personnel Selection Board is participated by PWD sector through:
☐ LGU employee with disability
☐ GA-nominated observer

5b3 Persons with Disability Affairs Officer

☐ Designated Persons with Disability Affairs Officer/ Focal person

6 Residential Care Facility for the vulnerable sectors Has LGU-managed

RCF that has valid
accreditation?
6.1 The facility is managed by the LGU, and has:
☐ Yes
☐ (N) DSWD-accreditation; period of effectivity: ______________________ ☐ No
☐ Ongoing application for DSWD-accreditation
☐ Newly-established facility, operation is less than 1-year Or: [CONSIDERATION]
with partner-RCF that
has valid
6.2 Facility managed by:
accreditation?
☐ DSWD-FO; period of accreditation effectivity: ______________________ ☐ Yes
☐ Partner-LGU; period of accreditation effectivity: ______________________ ☐ No
☐ Partner-private Social Welfare and Development Agency; period of
accreditation effectivity: ______________________

6.2a Name of facility: ______________________

☐ Has DSWD-accreditation; period of effectivity: ______________________
☐ Has a standing partnership with the LGU demonstrated in a
Memorandum of Agreement, or in case of partnership with DSWD-FO
managed facility, proof of transfer of resident(s)
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

12
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
7 The Local Social Welfare and Development Office is: PSWDO who is: an
RSW and with CSC-
7.1 Headed by: attested
appointment, OR
Details of appointment
PSWDO was hired
Position Title : ____________________________________________ prior to 2007, but with
Date of RSW staff?
appointment : _____________________ ☐ Yes
Nature of ☐ Permanent ☐ No
appointment : ☐ Temporary
If no, [CONSIDERATION]
Status of CSC : ☐ With affixed signature of CSC Field Office representative LSWDO appointment
attestation ☐ LGU is CSC-accredited to take final actions on appointments falls in identified
☐ Appointment endorsed to CSC Field Office for attestation consideration cases
in technotes?
Date endorsed: _____________________ ☐ Yes
Registered : ☐ Yes; PRC license is valid until: _______________ ☐ No
social worker ☐ No; because (s)he was hired prior to RA 9433
☐ Not a registered social worker

7.2 Manned by staff who are registered licensed worker

No. of staff with PRC license: : _____________________
PRC license (of 1 staff) is valid until: : _____________________

8(N) The LGU’s Indigenous People mandatory representative: IPMR has certificate
and seats, receives
☐ Has Certificate of Affirmation issued by the NCIP Regional Office
compensation and
☐ Seats in the sanggunian attends, as a regular
☐ Receives compensation and other regular benefits of a sanggunian member sanggunian
member?
☐ Attends sanggunian sessions as indicated in the Minutes of the Meetings
☐ Yes
☐ Not applicable ☐ No
☐ NA
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

[END OF SOCIAL PROTECTION]

CERTIFICATION
We hereby certify that all information contained in this assessment report are true and correct, and are
correspondingly supported by documents and other means of verifications as reviewed by the undersigned.

Date: _________________________________
1. RAT Leader

_______________________________________________ ______________________________
Signature over Printed Name (1) DILG-Place of Assignment
2. Partner-CSO rep

_______________________________________________ ______________________________
(2) Signature over Printed Name (2) Name of Organization
3. Partner-NGA rep
______________________________
_______________________________________________ (3) Name of Agency
(3) Signature over Printed Name
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

13
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance Form P 3.4
CY 2019 Peace and Order

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form P 3.4 Peace and Order

Province of : __________________________________ Income Class :

Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the LGOO from the Province and onsite visit, please supply the required
information or tick applicable LGU condition under Column A. (2) For data provided by partner agencies –items marked with (N)- indicate
whether there is a discrepancy as compared to LGU data. Pending data reconciliation, RAT may carry the answer that favors the LGU. (3)
In case of a correction/erasure, RAT leader must affix signature parallel to corrected portion. (4) AFFIX SIGNATURE AT THE END OF EACH
ASSESSMENT AREA, and PUT INITIALS AT THE BOTTOM OF EACH PAGE. ONLY DULY ACCOMPLISHED FORMS ARE TO BE ENCODED BY THE RFP.

Column A Column B
Required Data Processing of
results
1(N) Passed the 2018 Peace and Order Council (POC) Performance Audit rating POC audit rating
passer?
☐ Yes
☐ Yes
☐ No ☐ No
If not a passer, must
meet items #2 and
#3
2 The Provincial Peace and Order Council convened: Convened in all
quarters?
☐ At least once in 1st quarter CY 2018
☐ Yes
☐ At least once in 2nd quarter CY 2018 ☐ No
☐ At least once in 3rd quarter CY 2018
☐ At least once in 4th quarter CY 2018
3 The LGU has adopted a Peace and Order, and Public Safety (POPS) Plan Has adopted
POPSPLAN covering
☐ Yes
CY 2018, and
☐ No completion/utilization
If yes, rate is at least 75%?
☐ Yes
Period covered by the Plan : ________ - ________
☐ No
Fund utilization rate
(based on accomplished Form P 2A: : ________%
Accountant Office)
Physical completion of PPAs
(based on accomplished Form P 2E: DILG : ________%
Field Office)

4 The LGU has activated its Anti-Drug Abuse Council (ADAC) (based on accomplished Form P 2I: ADAC has prescribed
composition and met
Local PNP Office/Station):
in all quarters?
☐ Yes
On composition ☐ No
☐ Organized as prescribed by DILG MC No.: 98-227 and 2012-94
☐ With accredited CSO/NGO representative(s) who form part of the council

On meetings
☐ Met at least once in 1st quarter, CY 2018
☐ Met at least once in 2nd quarter CY 2018
☐ Met at least once in 3rd quarter CY 2018
☐ Met at least once in 4th quarter CY 2018

14
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
5 The LGU has provided logistical support to PNP Provincial Police Station or Office in CY Support provided in
CY 2018?
2018 (based on accomplished Form P 2I: Local PNP Office/Station)
☐ Yes
☐ Yes ☐ No
☐ No

[END OF PEACE AND ORDER]

CERTIFICATION
We hereby certify that all information contained in this assessment report are true and correct, and are
correspondingly supported by documents and other means of verifications as reviewed by the undersigned.

Date: _________________________________
1. RAT Leader

_______________________________________________ ______________________________
Signature over Printed Name (1) DILG-Place of Assignment
2. Partner-CSO rep

_______________________________________________ ______________________________
(2) Signature over Printed Name (2) Name of Organization
3. Partner-NGA rep
______________________________
_______________________________________________ (3) Name of Agency
(3) Signature over Printed Name
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

15
 Department of the Interior and Local Government Form P 3.5
Assessment for the Seal of Good Local Governance Business-friendliness &
CY 2019 Competitiveness

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form P 3.5 Business-friendliness & Competitiveness

Province of : __________________________________ Income Class :

Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the LGOO from the Province and onsite visit, please supply the required
information or tick applicable LGU condition under Column A. (2) For data provided by partner agencies –items marked with (N)- indicate
whether there is a discrepancy as compared to LGU data. Pending data reconciliation, RAT may carry the answer that favors the LGU. (3)
In case of a correction/erasure, RAT leader must affix signature parallel to corrected portion. (4) AFFIX SIGNATURE AT THE END OF EACH
ASSESSMENT AREA, and PUT INITIALS AT THE BOTTOM OF EACH PAGE. ONLY DULY ACCOMPLISHED FORMS ARE TO BE ENCODED BY THE RFP.

Column A Column B
Required Data Processing of
results
1(N) The LGU has been recognized in 2018 for its efforts in business promotion and PCCI awardee?
☐ Yes
investments, and enhancing its competitiveness by being a finalist of PCCI’s Most
☐ No
Business-Friendly LGUs award
☐ Yes If not an awardee,
☐ No must meet items #2
to #4
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

2 The LGU supports local economic and investment promotion through: Has a LEIP office?
☐ Establishing an office for local economic and investment promotion ☐ Yes
☐ No
☐ Designated an officer for local economic and investment promotion
3 The LGU has a Local Investment and Incentives Code. Code updated not
☐ Yes; year adopted: ___________ earlier than 2014?
☐ Yes
☐ Passed ordinance(s) amending/revising existing Code in year: ___________
☐ No
☐ No Investment and Incentive Code
Or: [CONSIDERATION]
updated not
earlier than 2009?
☐ Yes
☐ No

4 The LGU is a beneficiary of Conditional Matching Grant to Provinces (formerly KALSADA CMGP-
Program) and fund utilization is (based on accomplished Form P 2A: Accountant’s Office; put N/A for beneficiary?
not applicable items): ☐ Yes
☐ No
CY 2016 CY 2017
Total amount PhP ____________________ PhP ___________________ If yes, full utilization
Amount utilized PhP ____________________ PhP ___________________ of CY 2016 funds,
and at least 60%
Percent-utilization is ______ % ______ %
for CY 2017?
Not applicable ☐ ☐ ☐ Yes
☐ No
☐ Not
applicable

[END OF BUSINESS-FRIENDLINESS & COMPETITIVENESS]

16
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

CERTIFICATION
We hereby certify that all information contained in this assessment report are true and correct, and are
correspondingly supported by documents and other means of verifications as reviewed by the undersigned.

Date: _________________________________
1. RAT Leader

_______________________________________________ ______________________________
Signature over Printed Name (1) DILG-Place of Assignment
2. Partner-CSO rep

_______________________________________________ ______________________________
(2) Signature over Printed Name (2) Name of Organization
3. Partner-NGA rep
______________________________
_______________________________________________ (3) Name of Agency
(3) Signature over Printed Name
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

17
 Department of the Interior and Local Government Form P 3.6
Assessment for the Seal of Good Local Governance Environmental Management
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form P 3.6 Environmental Management

Province of : __________________________________ Income Class :

Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the LGOO from the Province and onsite visit, please supply the required
information or tick applicable LGU condition under Column A. (2) For data provided by partner agencies –items marked with (N)- indicate
whether there is a discrepancy as compared to LGU data. Pending data reconciliation, RAT may carry the answer that favors the LGU. (3)
In case of a correction/erasure, RAT leader must affix signature parallel to corrected portion. (4) AFFIX SIGNATURE AT THE END OF EACH
ASSESSMENT AREA, and PUT INITIALS AT THE BOTTOM OF EACH PAGE. ONLY DULY ACCOMPLISHED FORMS ARE TO BE ENCODED BY THE RFP.

Column A Column B
Required Data Processing of
results
1 The LGU has a Solid Waste Management Board that: SWM has
☐ Is organized according to composition prescribed in Sec. 12 of Ecological Solid prescribed
Waste Management Act with a representative from NGO sector that promote composition and
met at least once
recycling and the protection of air and water quality as Board member
in CY 2018?
☐ Convened in CY 2018; ☐ Yes
Please indicate date of latest Board meeting: _____________________________ ☐ No
2(N) The LGU has a 10-Year Solid Waste Management Plan that is: Has an approved
☐ Already approved by NSWMC Plan?
☐ Yes
☐ Submitted for review to the NSWMC
☐ No
☐ None
Or: [CONSIDERATION]
2.1 Status of SWM Plans of component cities and municipalities (CM) Plan is already
Total no. of component cities and municipalities submitted to
NSWMC?
________ ☐ Yes
No. of component CMs with SWM Plan that is: ☐ No
(a) Already approved ________ Or: [CONSIDERATION]
(b) Submitted for review ________ at least 75% of
component CMs
In %: ________ have approved/
To compute: (Sum of a, b and c/ total component
submission?
CMs) x 100
☐ Yes
☐ No
LGU-NGA Data Discrepancy Check (tick as appropriate):
☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy

[END OF ENVIRONMENTAL MANAGEMENT]

18
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

CERTIFICATION
We hereby certify that all information contained in this assessment report are true and correct, and are
correspondingly supported by documents and other means of verifications as reviewed by the undersigned.

Date: _________________________________
1. RAT Leader

_______________________________________________ ______________________________
Signature over Printed Name (1) DILG-Place of Assignment
2. Partner-CSO rep

_______________________________________________ ______________________________
(2) Signature over Printed Name (2) Name of Organization
3. Partner-NGA rep
______________________________
_______________________________________________ (3) Name of Agency
(3) Signature over Printed Name
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

19
 Department of the Interior and Local Government Form P 3.7
Assessment for the Seal of Good Local Governance Tourism, Culture and
CY 2019 the Arts

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form P 3.7 Tourism, Culture and the Arts

Province of : __________________________________ Income Class :

Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the LGOO from the Province and onsite visit, please supply the required
information or tick applicable LGU condition under Column A. (2) For data provided by partner agencies –items marked with (N)- indicate
whether there is a discrepancy as compared to LGU data. Pending data reconciliation, RAT may carry the answer that favors the LGU. (3)
In case of a correction/erasure, RAT leader must affix signature parallel to corrected portion. (4) AFFIX SIGNATURE AT THE END OF EACH
ASSESSMENT AREA, and PUT INITIALS AT THE BOTTOM OF EACH PAGE. ONLY DULY ACCOMPLISHED FORMS ARE TO BE ENCODED BY THE RFP.

Column A Column B
Required Data Processing of
results
TOURISM DEVELOPMENT
LGU Tourism Profile: Please tick available condition (based on accomplished Form P 2H: Planning If condition (c) is
and Development Office) (tick one item only): ticked, this sub-
☐ (a) LGU hosts a destination which form part of the brand “Philippine Tourism” area is not
☐ (b) Tourism is a significant industry in the LGU applicable
☐ (c) Tourism is NOT a significant industry in the LGU
1 The LGU has a tourism officer who holds permanent position If condition (a) or
☐ Yes (b) is ticked in
☐ No, but there is a designate Tourism Profile,
must have TWO of
☐ None the following: (i)
2 The LGU has a tourist information and assistance center/desk (based on accomplished Form P permanent officer;
2E: DILG Field Office) (ii) info and
☐ Yes assistance
☐ None center/desks; and
3 The LGU has a tracking system for local tourism statistics (iii) tracking of at
☐ Yes, computerized mode of recording least 2 tourism
data?
☐ Yes, computer-aided mode of recording
☐ Yes
☐ Yes, manual mode of recording ☐ No
☐ None ☐ Not
applicable
3.1 Tourism statistics available (please indicate summarized data)
No. of tourist arrivals : ____________________________
No. of tourism enterprises : ____________________________
No. of accommodations : ____________________________
No. of tour operators : ____________________________
CULTURAL HERITAGE PROMOTION AND CONSERVATION
4 The LGU has a local council for culture and the arts Constituted a
☐ Yes; Date constituted: ______________________ council?
☐ No ☐ Yes
☐ No
5 The LGU appropriated budget for the conservation and preservation of cultural Utilization of
property in CY 2018 budget is at least
☐ Yes; Percent-utilization of said budget is (based on accomplished Form P 2A: 75%?
☐ Yes
Accountant’s Office): __________ %
☐ No
☐ No
6 The LGU has a cultural property inventory/registry which contains: An inventory has
☐ Names of property all required
☐ Significance information that is:
(a) updated not
☐ Type earlier than 2017;
☐ In photograph/multimedia file and (b) submitted

20
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Column A Column B
Required Data Processing of
results
☐ Location (recorded, but kept confidential) to NCCA (OR
☐ Ownership(recorded, but kept confidential) [CONSIDERATION] yet
to be submitted)?
☐ Yes
Inventory is:
☐ No
6.1 Last updated in (please indicate date): _________________
6.2 Adopted by Sanggunian through:
☐ Ordinance
☐ Resolution
Date adopted: _________________
6.3 Already submitted to NCCA for review in (please indicate date): ________________

7 The LGU‘s history and culture is documented and published in: Has published
☐ LGU’s official website narrative on history
☐ Magazines/newsletters and culture using
any listed
☐ Books medium?
☐ Digital media; please specify: ____________________________________ ☐ Yes
☐ Other form; please specify: ____________________________________ ☐ No
Passed at least
three of four
indicators for this
sub-area?
☐ Yes
☐ No

[END OF TOURISM, CULTURE AND THE ARTS]

CERTIFICATION
We hereby certify that all information contained in this assessment report are true and correct, and are
correspondingly supported by documents and other means of verifications as reviewed by the undersigned.

Date: _________________________________
1. RAT Leader

_______________________________________________ ______________________________
Signature over Printed Name (1) DILG-Place of Assignment
2. Partner-CSO rep

_______________________________________________ ______________________________
(2) Signature over Printed Name (2) Name of Organization
3. Partner-NGA rep
______________________________
_______________________________________________ (3) Name of Agency
(3) Signature over Printed Name
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

21