SPECIAL ASSISTANCE FOR RECOVERY AND ALLEVIATION PROGRAM

2022 2023
NEEDS ASSESSMENT FORM
Post-Disaster/Calamity Needs Assessment Cooperatives
For the year ___________
COOPERATIVE BASIC PROFILE
Name of Cooperative:
Coop Registration No:
Postal Address:
Contact Person:
Tel No/Cell No:
Email Address:
Type of Cooperative:

Total Membership:
Male
Female
Total Assets
Net Surplus

1. DESCRIPTION OF CURRENT BUSINESS ACTIVITY/SERVICES:

Klase/Uri ng kasalukuyang negosyo ng kooperatiba:

Value of Derived Sales (or Loans

Transaction
Business Type Released to Members)
Type /1
Klase/Uri ng Pangkasalukuyang (in Pesos)
Uri ng
Negosyo Halaga ng Kinita mula sa
Transaksyon
Negosyong ito

Please use additional sheet/s if necessary

1/ Type of Transaction may be
A-cooperative to individual
B-cooperative to cooperative
C-cooperative to corporation
D-cooperative with external export/import transaction

Other details of business activities:

Iba pang detalye ng nasabing mga klase/uri ng negosyo:

2. FINANCIAL SUPPORT PROJECT NEEDED

Mga programa at gawaing pangkabuhayan at negosyong pinapanukala ng
kooperatiba na maaaari nilang isagawa

3. SOCIAL PREPARATION:
Mga aktibidades bago makatanggap ng tulong ang kooperatiba
This form is in observation to CDA Memo Circular No. 2020-09 re. “Guidelines for Accreditation of Cooperative
Beneficiaries of CDA-Administered Grants and Donations Involving Public Funds and Properties,” specifically
“Section 8. Social Preparation”
 Mark check ✔if
received/conducted
Markahan ng tsek ✔ kung
natanggap o naganap
CDA-Mandated Seminar
and Trainings
Orientation and/or coordination with Local Government
Units and/or Inter-Agency Representatives at all Levels
CDA personnel visit and/or coordination with coop to area
of operation/s affected by the calamity/disaster

4. PROPERTY OF THE COOPERATIVE DAMAGED BY THE TYPHOON/CALAMITIES/

DISASTERS/ OTHERS
Mga pag-aari at kagamitan ng kooperatiba/asosasyon na nawala o nasira ng bagyo/
kalamidad/ sakuna at iba pang katulad nito

Properties damaged by the typhoon/ Amount of Damage

Halaga ng
Mga pag-aari at kagamitan ng kooperatiba/asosasyon na nawala o
Nasira/Nawala
nasira ng bagyo/ kalamidad/ sakuna at iba pang katulad nito
(in Pesos)
Agricultural produce or materials
Consumer inventories
Office Supplies
IT Equipment and Software
Communication Equipment
Furniture and Fixtures
Livestock Inventory
Other Agricultural, Fishery and Forestry Products Inventory, specify:
Buildings
Construction and Heavy Equipment
Other Machineries and Equipment, specify:
Motor Vehicles
Other Transportation Equipment, specify:
Other Property, Plant and Equipment, specify:
Others, specify:
Others, specify:
TOTAL (Kabuuang halaga ng Nasira/Nawala)

Assessed by: Confirmed true and correct by:

Coop Accountant/Bookkeeper Cooperative

or Chairman/Representative
Coop Treasurer/Cashier or
Evaluator/Assessor

Examined/Verified by: Reviewed by: Noted by:

CDS II/ Field examiner/verifier Senior CDS/Senior Evaluator Director, CDA-XXXX Extension
Office

This form is in observation to CDA Memo Circular No. 2020-09 re. “Guidelines for Accreditation of Cooperative
Beneficiaries of CDA-Administered Grants and Donations Involving Public Funds and Properties,” specifically
“Section 8. Social Preparation”