10/13/21, 12:45 PM TEST ESMF 1: Rapid Environmental and Social Screening Form for CCLOA

TEST ESMF 1: Rapid Environmental and Social Screening

Form for CCLOA
To be accomplished by the DARPO Provincial ESS Staff (Organic), verified by DARPO ESS Coordinator (Organic) and approved
by Provincial Agrarian Reform Program Officer (Organic)

Collective CLOA Sequence Number

OCT/TCT Number

Collective CLOA Number

Collective CLOA Date of Registration (mm/dd/yyyy)

Projection Maps from NAMRIA/Certification/Approved Subidivision Plan

Upload a copy of the Projection Map from NAMRIA/Approved Subdivision Plan

Click here to upload file. (< 10MB)

Upload a copy of NAMRIA Certification

Click here to upload file. (< 10MB)

Date of Certification (mm/dd/yyyy)

I. Technical Description/Location
Lot Area (in square meters)

Region

Province

Municipality/ies

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Barangay/s

II. Assessment of Collective CLOA for Overlaps

1. FOREST LANDS

Yes

No

Classification of FORESTLAND overlap

Timberland

Unclassified Forest Land

Watershed

Total area of overlap (in square meters)

May require RPF1A Attachment if needed

Total remaining area for parcelization (in square meters)

2. Protected Areas, National Parks, and/or Natural Habitats

Yes

No

Total area of overlap (in square meters)

May require RPF1A Attachment if needed

Total remaining area for parcelization (in square meters)

2.1 Check which applies

Strict nature reserves

Natural parks

Natural monuments

Wildlife sanctuary

Protected landscapes and seas

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3. Cultural Heritage and/or Natural Heritage Areas

Yes

No

Total area of overlap (in square meters)

May require RPF1A Attachment if needed

Total remaining area for parcelization (in square meters)

3.1 Check which applies

Works of Natural Artists

Archaeological and Traditional Ethnographic Materials

Works of National Heroes

Marked Structures

Structures dating at least 50 years old

Archival material/document dating at least 50 years old

Others

4. Ancestral Domain

Yes

No

4.1 Which IP Title was issued?

CADT - Certificate of Ancestral Domain Title

CALT - Certificate of Ancestral Land Title

4.1A Registration Date of Certificate of Ancestral Domain Title (CADT) (mm/dd/yyyy)

4.1B Registration Date of Certificate of Ancestral Land Title (CALT) (mm/dd/yyyy)

Please proceed to IPPF attachments.

Total area of overlap (in square meters)

Total remaining area for parcelization (in square meters)

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III. ARB and CCLOA

Total Number of Agrarian Reform Beneficiaries (ARBs) annotated in the Collective CLOA

» List of ARBs Annotated in the Collective CLOA

1
First Name

Middle Name

Last Name

Gender

Male

Female

Name of Spouse

Number of Male Agrarian Reform Beneficiaries (ARBs) annotated in the Collective CLOA

Number of Female Agrarian Reform Beneficiaries (ARBs) annotated in the Collective CLOA

» ARB Organizations

Are there ARB organization/s in the Collective CLOA area?

Yes

No

1
Name of the ARB Organization/s (DAR assisted)

Total number of ARB organizations

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Are the ARBs members of the organization/s?

Yes

No

Government Support Services

Is the Collective CLOA area covered by previous or current DAR programs?

Yes

No

Which type of DAR Support Services?

Credit Assistance

Marketing Assistance

Basic Social Services

CRFP/Physical Infrastructure

Pre-post Harvest Facilities

Livelihood Assistance

Agri Extension

Others

Please specify DAR Support Service

Please specify Basic Social Services

Health

Potable Water

Education

Electricity

Housing

Others

Please specify

Please specify Marketing Assisitance

VLFED

LINKSFARM

ARBOLD

Others

Please specify

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Please specify CRFP/Physical Infrastructure

Farm to Market Road

Irrigation Facilities

Bridges

Farm Equipment

Others

Please specify

Please specify Agri Extension

FBS

Others

Please specify

Is the Collective CLOA covered by previous or current support services from other government agencies?

Yes

No

Check which Government Agency applies

Department of Agriculture

Department of Environment and Natural Resources

Technical Education and Skills Development Authority

Department of Social Welfare and Development

Bureau of Soils and Water Management

Department of Interior and Local Government

Local Government Unit

Department of Trade and Industry

Others

Please specify

Is the Collective CLOA covered by previous or current support services from nongovernment organizations?

Yes

No

Which nongovernment organization?

Nongovernment Organizations

Civil Society Organizations

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Please specify NGOs

Please specify CSOs

Are there previous or current Foreign Assisted Projects existing in the area?

World Bank

Japan International Cooperation Agency - JICA, ARISP

Asia Development Bank - ADB

Others

None

Please specify

Prepared by:
DARPO ESS Support (Organic)

Upload a copy of your e-signature

Click here to upload file. (< 10MB)

Upload a photo of your Official DAR ID

Click here to upload file. (< 10MB)

Verified by:
DARPO Provincial ESS Coordinator (Organic)

Upload a copy of your e-signature

Click here to upload file. (< 10MB)

Upload a photo of your Official DAR ID

Click here to upload file. (< 10MB)

Approved by
Provincial Agrarian Reform Program Officer

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Upload a copy of your e-signature

Click here to upload file. (< 10MB)

Upload a photo of your Official DAR ID

Click here to upload file. (< 10MB)

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