10/13/21, 12:40 PM TEST ESMF 3A: Individual ARB Environmental & Social Performance (IA-ESP) Assessment

TEST ESMF 3A: Individual ARB Environmental & Social

Performance (IA-ESP) Assessment
To be accomplished by the FVT Team Leader, ESS Staff, and ESS Documenter (COS), verified by the Provincial ESS Coordinator
(Organic) and approved by the Provincial Agrarian Reform Program Officer (Organic)

Collective CLOA Sequence Number

OCT/TCT Number

Collective CLOA Number

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

ARB Profile
First Name

Middle Name

Last Name

Lot # of the actual area of tillage/cultivation (based on the Approved Subdivision Plan if available)

Actual area of tillage/cultivation (in square meters)

Is the ARB still in possession?

Yes

No

ARB cannot be found or no longer in the Collective CLOA.

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Upload a Photo/Selfie with the ARB

Click here to upload file. (< 10MB)

Date of Birth (mm/dd/yyyy)

Gender

Male

Female

Is the ARB a member of any ARB Organization?

Yes

No

Please specify ARB Organization/s (DAR Assisted)

Are there support services from DAR currently being availed or have been availed by the ARB?

Yes

None

Select the support service/s availed

Capacity Development

Credit/Microfinance Assistance

Farm Tools/Equipment

Farmer Business School

Others

Please specify Capacity Development

Please specify Credit/Microfinance Assistance

Please specify Farm Tools/Equipment

Please specify Farm Business School

Please specify

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Is the ARB a member of any ICC/IP Community?

Yes

No

Prepare IPPF Attachments.

Is there an issue of overlap in the actual area of tillage/cultivation of the ARB?

Yes

No

Prepare RPF 1A Attachment if needed.

ARB Additional Information

Educational Attainment

Elementary

Highschool

Post Secondary

College

Post Graduate

None

Civil Status

Single

Married (Legally married)

Separated

Widowed

Common-Law Partner (Legally capacitated to marry pursuant to the Family Code)

Total Number of Children (Single, Separated, Widowed)

» Children Information (Single, Separated, Widow)

Are any of the children involved in farming activities?

Yes

No

Please specify

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Are any of the children engaged in off-farm/non farm livelihood activities?

Yes

No

Please specify

» Spouse Information (Legally Married)

First Name

Middle Name

Last Name

Gender

Male

Female

Educational Attainment

Elementary

Highschool

Post Secondary

College

Post Graduate

None

Is the spouse actually tilling the same Collective CLOA parcel?

Yes

No

Is the spouse engaged in off-farm/non farm activities?

Yes

No

Please specify

Total Number of Children (Spouse)

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» » Children Information (Spouse)

Are any of the children involved in farming activities?

Yes

No

Pease specify

Are any of the children engaged in off-farm/non farm livelihood activities?

Yes

No

Please specify

» For Muslim and Other Indigenous Communities Allowing Multiple Marriages

1
First Name

Middle Name

Last Name

Gender

Male

Female

Educational Attainment

Elementary

Highschool

Post Secondary

College

Post Graduate

None

Is the spouse actually tilling the same Collective CLOA parcel?

Yes

No

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Is the spouse engaged in off-farm/non farm activities?

Yes

No

Please Specify

Total Number of Children (Spouse)

» » Children Information

Are any of the children involved in farming activities?

Yes

No

Please specify

Are any of the children engaged in off-farm/non farm livelihood activities?

Yes

No

Please specify

» Common-Law Partner Information (Legally capacitated to marry pursuant to the Family Code)

First Name

Middle Name

Last Name

Gender

Male

Female

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Educational Attainment

Elementary

Highschool

Post Secondary

College

Post Graduate

None

Is the common-law partner actually tilling the same Collective CLOA parcel?

Yes

No

Is the common-law partner engaged in off-farm/non farm activities?

Yes

No

Please specify

Total Number of Children (Common Law Partner)

» Children Information (Common Law Partner)

Are any of the children involved in farming activities?

Yes

No

Please specify

Are any of the children engaged in off-farm/non farm livelihood activities?

Yes

No

Please specify

ARB Household
Is the ARB the head of the Household?

Yes

No

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Total Number of Household Members

Are there extended families living within the household?

Yes

No

Please specify affinity

Number of individuals

Are there nursing mothers in the household?

Yes

No

How many?

Are there any senior citizens in the household?

Yes

No

How many?

Are there any single parent in the household?

Yes

No

How many?

Are there any PWD in the household?

Yes

No

How many?

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Type of Disability

Is there anyone in the household with lingering health condition/illness?

Yes

No

How many?

Type of illness/es

Location of Home

Within the actual tillage/cultivation

Outside the actual tillage/cultivation

Please specify the address

Indicate the size and describe the materials of your house

Example: 2 storey, cement house, 45 sqm

Source of power

Source of water

Prepared by:
Field Validation Team ESS Staff or ESS Documenter (COS)

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)

Reviewed by:
Field Validation Team Leader (COS)

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10/13/21, 12:40 PM TEST ESMF 3A: Individual ARB Environmental &amp; Social Performance (IA-ESP) Assessment

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:
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

Upload a photo of your Official DAR ID

Click here to upload file. (< 10MB)

Upload a copy of your e-signature

Click here to upload file. (< 10MB)

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