Department of the Interior and Local Government Form CM 3.

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

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form CM 3.1 Financial Administration

City/Municipality of : __________________________________ Income Class :

Province : __________________________________ Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the C/MLGOO 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 OR PFP.

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 CM 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 ☐ Has Sanggunian-approved Comprehensive
Development Plan
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 CM 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 CM 2K: Treasurer’s Office) Full utilization of
Utilized amount out of DF : PhP ____________________ Development
Fund?
In percent (LDF utilized/20% of
☐ Yes
IRA) x 100 : ______ %
☐ No
LGU-NGA Data Discrepancy Check (tick as appropriate): [CONSIDERATION]If
no,
☐ Data differ; included in the accomplished Change Request Form met benchmark at
☐ No data discrepancy least?
☐ Yes
☐ No

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

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

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(N) The LGU is a beneficiary of Assistance to Municipalities program (DILG-managed AM-beneficiary?

funds only), and: ☐ Yes
☐ No
Fund utilization is (based on accomplished Form CM 2A: Accountant’s Office; put N/A for not
applicable items) If yes, full utilization
CY 2015 CY 2016 CY 2017 for CY 2015 and
2016; AND met
Total amount PhP ______________ PhP _____________ PhP ____________ 85% benchmark
for CY 2017?
PhP ______________ PhP _____________ PhP ____________ ☐ Yes
Amount utilized
☐ No

% utilization ______ % ______ % ______ %

Not applicable ☐ ☐ ☐

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

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

3
 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
8 The LGU’s Annual Budget is: Budget approved
☐ Approved; date of approval: _______________________ by Dec. 31, 2018?
☐ Re-enacted ☐ Yes
☐ No

[CONSIDERATION]
If not, budget
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) Name of Agency
(3) Signature over Printed Name
Official Release of this Form: (Please affix release stamp of DILG RO/PO here)

4
 Department of the Interior and Local Government Form CM 3.2
Assessment for the Seal of Good Local Governance Disaster Preparedness
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form CM 3.2 Disaster Preparedness

City/Municipality of : __________________________________ Income Class :

Province : __________________________________ Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the C/MLGOO 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 OR PFP.

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
If not an awardee,
LGU-NGA Data Discrepancy Check (tick as appropriate): 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 Local Disaster Risk Reduction and Management Council: Met all conditions
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

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
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 CLUP approved?
4 The LGU has a Comprehensive Land Use Plan that is: ☐ Yes
☐ No
☐ (N) Approved; period covered is _________ to _________
[CONSIDERATION]
☐ Not yet approved
If no, draft CLUP is
Latest duly approved Plan : under review and
period of effectivity ________________________________ contains risk
Status : ☐ Under review of PLUC or Regional HLURB assessment results?
☐ Currently updating ☐ Yes
☐ Currently drafting ☐ No
Draft CLUP : ☐ 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 CM 2C)

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
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 CLUP or CDP ☐ 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 CM 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 Form 70% component of
CM 2A: Accountant’s Office) LDRRMF utilized?
Total amount of 70% ☐ Yes
component : PhP ____________________ ☐ No

Amount utilized : PhP ____________________

In percent : ______ %

9 Percentage of barangays with approved community-based disaster risk reduction and At least 75% of
management (CBDRRM) plan (based on accomplished Form CM 2F: DRRM Office) is: ________% brgys w/ CBDRRM
plan?
☐ Yes
☐ No

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
10 The LGU has an early warning system (EWS) which includes (based on accomplished Form EWS present (10a,
CM 2E: DILG Field Office): 10b, 10c, and
either in 10c)?
☐ Yes
Present None
☐ No
10a At least one (1) marker present in high risk area of:
- Top 1 hazard ☐ ☐
- Top 2 hazard ☐ ☐
10b Warning and alarm system is audible and wide-ranging ☐ ☐
10c Available equipment is:
- Automated rain gauge ☐ ☐
-Locally-innovated technology ☐ ☐
10d Info on EWS present in conspicuous places ☐ ☐

11a Evacuation management – Evacuation center (EC) Has an identified

EC with all
Indicate name of identified minimum required
facilities present?
evacuation center (one center only) ________________________________________
☐ Yes
Location ________________________________________ ☐ No
Status of identified EC ☐ Permanent
☐ 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) satisfied all
☐ Kitchen area
conditions for
☐ Water supply 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

11b Evacuation management – Evacuation information guides At least 75% of

brgys have info
Please indicate percent of barangays with evacuation guide (based on accomplished guide?
☐ Yes
Form CM 2F: DRRM Office): ________%
☐ No

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
11c 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
comforting and processing after (national/local) service
the disaster ☐ Partnership with private/ NGO entities

System to ensure peace and order ☐ Present

and security in the event of ☐ None
disasters

12 Standard Operating Procedures are available. Has SOP?

☐ Yes ☐ Yes
☐ No ☐ No
12a SOP – LDRRM Operations Center Permanent OpCen
for HUC;
The LGU has an LDRRM OpCen that is: Temporary OpCen
at least for
☐ Permanent (functions 24/7 daily)
component CMs ?
☐ Temporary (functions 24/7 during disasters) ☐ Yes
☐ No
12b SOP–Trained and equipped SAR or ER teams Organized w/in
last three years?
12b1 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
12b2 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 ☐ ☐

9
 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
12c 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 _______ _______
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
Note that 4th – 6th Class municipalities has an ANY TWO of the three rule for 12(a), 12(c.2) and 12(d)]

[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)

10
 Department of the Interior and Local Government Form CM 3.3
Assessment for the Seal of Good Local Governance Social Protection
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form CM 3.3 Social Protection

City/Municipality of : __________________________________ Income Class :

Province : __________________________________ Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the C/MLGOO 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 OR PFP.

Column A Column B
Required Data Processing of
results
1(N) The LGU is a 2018 Seal of Child-friendly Local Governance recipient. Seal of Child-friendly
LG awardee?
LGU-NGA Data Discrepancy Check (tick as appropriate): ☐ Yes
☐ Data differ; included in the accomplished Change Request Form ☐ No
☐ No data discrepancy
([CONSIDERATION]
If no, passed per
DILG-RO level rating?
☐ Yes
☐ No

2 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 CM 2D: Dep Ed Representative): _______%
utilization rate?
☐ Yes
2.1 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: ______________________________________

3a The following mechanism in support of gender and development is present: Has items 3a1 to
3a3?
☐ Yes
☐ 3a1 GAD Focal point system ☐ No
☐ 3a2 GAD database
-AND-
☐ 3a3 CY 2018 GAD accomplishment report
Code is updated not
earlier than CY 2014,
3a4 GAD Code or [CONSIDERATION]
☐ City/Municipal code; year adopted: ___________ updated not earlier
☐ Passed ordinance(s) amending/revising existing Code in year: than CY 2009?
☐ Yes
___________ ☐ No
☐ Localized Provincial GAD code; Provincial Code adopted in year:
_________ -AND-

Guideline-compliant
3a5 CY 2019 GAD Plan and Budget Plan and Budget, or
☐ Reviewed and was found fully compliant in form and content per [CONSIDERATION]
PCW-DILG-DBM-NEDA JMC No. 2016-01 (based on accomplished Form CM submitted for review
2E: DILG Field Office) at least?
☐ Yes
☐ Submitted at least to DILG officer for review ☐ No

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
3b Establishing Barangay Violence Against Women and their Children (VAWC) desks Has 100% brgys w/
VAWC desks, and at
(based on accomplished Form CM 2J:SWD Office):
least 80% brgys
w/reports for all
3b1 ______% of barangays have respective VAWC desks quarters?
☐ Yes
3b2 Percentage of barangays that submitted VAWC reports for: ☐ No

CY 2018 % of barangays
1st quarter ______%
2nd quarter ______%
3rd quarter ______%
4th quarter ______%

4 The LGU has a Code for Children: Has own Code that is
updated not earlier
☐ Separate City/Municipal Code for Children; year adopted: ___________
than 2014?
☐ Integrated in another Code; year adopted: ___________ ☐ Yes
☐ Passed ordinance(s) amending/revising existing Code in year: ___________ ☐ No
☐ Localized the Provincial Code for Children; Provincial Code adopted in: Or [CONSIDERATION]
________ adopted own code/
☐ No Code for Children Province’s updated
not earlier than CY
2009?
☐ Yes
☐ No

5a(N) For HUCs only: Philhealth-accreditation of health facilities (based on accomplished Form HUC has at least
HUC 2L: Health Office) 50% facilities
accredited for
MCP, PCB and TB-
No. of LGU-run hospitals ___________ DOTS?
No. of main health center ___________ ☐ Yes
Total no. of facilities ___________ ☐ No
No. of Philhealth-accredited facilities (CY 2018/ 2019) for:
- MCP ___________ _____ %
- PCB ___________ _____ %
- TB-DOTS ___________ _____ %
To compute for each percentage: (no. of accredited facilities for a service/total no. of
facilities) x 100

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

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

5b(N) For ICCs/CCs/Municipalities: Philhealth-accreditation of health facilities ICC/CC has at least

1 facility that is 2019
or 2018 accredited,
5b1 LGU-managed health facilities
for MCP, PCB and TB-
CY 2019 CY 2018 DOTS?
accredited accredited ☐ Yes
No. of LGU health facility with Philhealth-accreditation for: ☐ No
Maternal Care Package (MCP) ______ ______
Primary Care Benefits (PCB) ______ ______ Municipality has at
TB-Directly Observed Treatment Short Course ______ ______ least 1 facility that is
2019 or 2018
(TB-DOTS)
accredited for MCP,
plus PCB or TB-DOTS?
☐ Yes
☐ No

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
5b2 There is a provincial or district hospital located in the LGU, and said hospital is -OR-
Philheath-accredited: [CONSIDERATION]
CY 2019 CY 2018 City/municipality has
accredited accredited a hospital located in
Accreditation-level the LGU that is 2019
Level I ______ ______ or 2018 accredited?
☐ Yes
Level II ______ ______
☐ No
Level III ______ ______

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

☐ Data differ; included in the accomplished Change Request Form
☐ No data discrepancy
6a 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 CM 2E: DILG Field Office):
met both conditions
under (ii); falls under
6a.1 Entrance/exit of LG building (iii) (iv) (v); OR
Physical feature/condition City/Mun Main hospital/ [CONSIDERATION] met

Hall health center both conditions

under (v);
(i) Has ramps:
[CONSIDERATION] met
- That passed the Gradient Finder test ☐ ☐ both conditions
- With 2-level handrail both sides ☐ ☐ under (vi)
(ii) Has ramps adjacent to a wall:
- Width is less than 1.20m ☐ ☐ For C/M Hall: Any of
above-enumerated
- Two-level handrail in one side ☐ ☐
parameter?
(ii) Ground level entrance or exit ☐ ☐ ☐ Yes
(iii) Dropped curb ☐ ☐ ☐ No
(iv) With special lift or elevator at the ground level ☐ ☐
(v) LG building is a historical site -AND-
- Certified by NHIP ☐ ☐ For main health
- Has facility/building catering to all PWD-related ☐ ☐ center: Any of
concerns/services above-enumerated
(vi) LG building is under construction parameter met?
- Has facility/building catering to all PWD-related ☐ ☐ ☐ Yes
concerns/services ☐ No
- Construction plans include provision of ramps ☐ ☐
with 2-level handrails
6a.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 ☐ ☐
For C/M Hall: Met
(iii) Door is wheelchair-accessible ☐ ☐ required parameters
(iv) Has turning space ☐ ☐ or met consideration
(v) LG building is under construction at least?
- Construction plans include provision of toilet for ☐ ☐ ☐ Yes
PWD ☐ No
(vi) In case PWD toilet is located in upper floor, with ☐ ☐
-AND-
special lift or elevator at the ground level
(vii) No toilet for PWDs ☐ ☐ For main health
facility: Met required
parameters or met
consideration at
least?
☐ Yes
☐ No

13
 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
6b The LGU has an entity that leads program/project/activity for PWDs: HUC established
office and met all
6b1 Persons with Disability Affairs Office conditions in
recruitment process
☐ Established office through an ordinance
of PDAO head?
☐ Established office through an executive order ☐ Yes
☐ Appointed PDAO Head who is PWD ☐ No
☐ Appointed PDAO Head who is not PWD
Or: [CONSIDERATION] If
no, has a PDA focal
Details of appointment person?
Date of ☐ Yes
☐ No
appointment : _____________________________
Nature of ☐ Permanent ICC/CC or
appointment : ☐ Temporary municipality has
Status of CSC : ☐ With affixed signature of CSC Field Office appointed PDAO
Head, or a
attestation representative designated an
☐ LGU is CSC-accredited to take final actions officer/ focal person?
on appointments ☐ Yes
☐ No
☐ Copy of appointment endorsed to CSC
Field Office for attestation
Date endorsed: ______________________

6b2 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

6b3 Persons with Disability Affairs Officer

☐ Designated Persons with Disability Affairs Officer/ Focal person
7 For HUCs only: Residential Care Facility for the vulnerable sectors HUC has LGU-
managed RCF with
7.1 LGU-managed facility: valid accreditation?
☐ Yes
☐ (N) DSWD-accredited; period of effectivity: ______________________
☐ No
☐ Ongoing application for DSWD-accreditation
☐ Newly-established facility, operation is less than 1-year Or: [CONSIDERATION]
partner-RCF with
7.2 Facility managed by: valid accreditation?
☐ Yes
☐ DSWD-FO; period of accreditation effectivity: ______________________
☐ No
☐ Partner-LGU; period of accreditation effectivity: ______________________
☐ Partner-private Social Welfare and Development Agency; period of
accreditation effectivity: ______________________

7.2a 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

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
8 The Local Social Welfare and Development Office is: C/MSWDO is RSW
and with CSC-
8.1 Headed by: attested
appointment, OR
Details of appointment
C/MSWDO hired prior
Position Title : ____________________________________________ to 2007 but with RSW
staff?
Date of appointment ☐ Yes
: _____________________ ☐ No
Nature of ☐ Permanent
appointment : ☐ Temporary If no, [CONSIDERATION]
LSWDO appointment
Status of CSC : ☐ With affixed signature of CSC Field Office falls in identified
attestation representative consideration cases
☐ LGU is CSC-accredited to take final actions on in technotes?
☐ Yes
appointments ☐ No
☐ Copy of appointment endorsed to CSC Field Office
for attestation
Date endorsed: _____________________
Registered social : ☐ Yes; PRC license is valid until: _______________
worker ☐ No; because he/she was hired prior to the
enactment of RA 9433
☐ Not a registered social worker

8.2 Manned by staff who are registered licensed worker

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

9(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

10 Illegal dwelling units exist within LGU jurisdiction (based on accomplished Form CM 2H: Planning City has no illegal
and Development Office) dwelling units?
☐ Yes
☐ Yes
☐ No
☐ No
-OR-
10.1 LGU effort(s) to control, prevent and/or remove illegal dwelling units include(s):
At least 50%
☐ Ordinance prohibiting illegal settlements, relocation and/or reintegration of accomplishment of
informal settlers Plan or resettlement
☐ Task force, LGU Housing Office, or similar entity PPAs, OR
[CONSIDERATION] has
☐ Approved Local Shelter Plan, or approved Resettlement and Relocation ordinance + task
Action Plan; timeline of Plan: ____________________ force + approved
☐ Resettlement and relocation PPAs plan?
☐ Yes
☐ No
10.2 Accomplishment of targets on resettlement PPAs
Please indicate percent-accomplishment of CY 2018 targets is (based on
accomplished Form CM 2H: Planning and Development Office) : ____________________

15
 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
11(N) Provision of Potable Water Supply-Sagana at Ligtas na Tubig sa Lahat (SALINTUBIG) Has 100% financial
accomplishment for
projects: Financial accomplishment (based on accomplished Form CM 2A: Accountant’s Office; put
CY 2012 to 2016
N/A for not applicable items)
projects, AND at
least 50% financial
Year Total amount received Amount utilized In % accomplishment for
CY 2017?
☐ Yes
2012 PhP ____________________ PhP ___________________ ___% ☐ No
☐ Not
2013 PhP ____________________ PhP ___________________ ___% applicable

2014 PhP ____________________ PhP ___________________ ___%

2015 PhP ____________________ PhP ___________________ ___%

2016 PhP ____________________ PhP ___________________ ___%

2017 PhP ____________________ PhP ___________________ ___%

☐ Not applicable

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)

16
 Department of the Interior and Local Government Form CM 3.4
Assessment for the Seal of Good Local Governance Peace and Order
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form CM 3.4 Peace and Order

City/Municipality of : __________________________________ Income Class :

Province : __________________________________ Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the C/MLGOO 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 OR PFP.

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 City/Municipal 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 Adopted POPSPLAN
covering CY 2018,
☐ Yes
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 CM 2A: : ________%
Accountant Office)
Physical completion of PPAs
(based on accomplished Form CM 2E: : ________%
DILG Field Office)

4 The LGU has activated its Anti-Drug Abuse Council (ADAC) (based on accomplished Form CM ADAC has prescribed
composition and met
2I: 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

5 The LGU has provided logistical support to PNP City/Municipal Police Station or Office in Support provided in
CY 2018?
CY 2018 (based on accomplished Form CM 2I: Local PNP Office/Station)
☐ Yes
☐ Yes ☐ No
☐ No

17
 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
6 The LGU has Barangay Peacekeeping Action Teams, barangay tanods and/or any BPATS is 100%
organized and 100%
similar unit, that are (based on accomplished Form CM 2I: Local PNP Office/Station):
trained?
________% organized ☐ Yes
________% trained ☐ No

7(N) Actions against illegal drugs: Drug-cleared barangays Drug-free or showed

increase in drug-
cleared barangays?
The LGU is a PDEA-declared drug-free city/municipality. ☐ Yes
☐ Yes ☐ Awaiting
☐ No data
☐ No

If not, PDEA data on drug-cleared barangays are as follows:

No. of drug-affected barangays as of Dec. 2017 _______________
No. of drug-cleared barangays
(a) CY 2018 _______________
(b) CY 2019 _______________

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

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

8 The LGU has an ordinance regulating firecracker and other pyrotechnic devices: Ordinance present?
☐ Yes
☐ Total ban of firecracker and other pyrotechnic devices
☐ No
☐ Designating zones for the sale, manufacture and use of firecracker and other
pyrotechnic devices

[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)

18
 Department of the Interior and Local Government Form CM 3.5
Assessment for the Seal of Good Local Governance Business-friendliness &
CY 2019 Competitiveness

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form CM 3.5 Business-friendliness & Competitiveness

City/Municipality of : __________________________________ Income Class :

Province : __________________________________ Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the C/MLGOO 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 OR PFP.

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 or
Top 50 in
investments, and enhancing its competitiveness by being:
Competiveness
☐ Finalist of PCCI’s Most Business-Friendly LGUs award Index?
☐ Ranked among the Top 50 of the Competitiveness Index ☐ Yes
☐ No
LGU-NGA Data Discrepancy Check (tick as appropriate): If not an awardee or
in Top50, must meet
☐ Data differ; included in the accomplished Change Request Form
items #2 to #7
☐ No data discrepancy

2 The LGU supports local economic and investment promotion through: City has a LEIP
☐ Establishing an office for local economic and investment promotion office?
☐ Yes
☐ Designated an officer for local economic and investment promotion
☐ No

Municipality has a
designated LEIP
officer at least?
☐ Yes
☐ No
3 The LGU has a Citizen’s Charter for securing permits for new business and business Has Citizen’s
renewal informing clients that: Charter compliant
☐ Application for new business has 3 steps or less with the listed
conditions?
☐ Application for business renewal has 3 steps or less ☐ Yes
☐ Processing time for new business permits of not more than 2 days ☐ No
☐ Processing time for business renewals of not more than one day from the day it
was applied for
3a Available option to further streamline process of business permit application is
present
☐ Co-location of local BFP with BPLO; This arrangement is:
☐ Permanent
☐ Temporary (seasonal)
☐ LGU is designated as collecting agent of BFP
4 Actual release of permits is within the prescribed period, as shown in the collected Compliant w/ the
business permit application samples (based on accomplished Form CM 2B: BPLO): prescribed no. of
4a New businesses: not more than 2 days days for actual
release of business
☐ Yes
permits for both
☐ No type of
4b Business renewal: not more than 1 day transactions?
☐ Yes ☐ Yes
☐ No ☐ No

19
 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 a Business One-Stop-Shop (BOSS) Has BOSS?
☐ Yes ☐ Yes
☐ No
☐ No
6 Data from business application forms are being tracked and summarized using this Has computerized
mode of recording: record of
☐ Manual economic data?
☐ Yes
☐ Computerized ☐ No
Kindly provide data on the following (based on accomplished Form CM 2B: BPLO):
2017 2018 HUC has All four
data tracked?
☐ Yes
6.1 Number of new businesses ________________ ________________
☐ No

6.2 Number of business renewals ________________ ________________ ICC/CC or

6.3 Amount of capital investment derived from municipality has at
registered new businesses and business renewals ________________ least 3 data
6.4 Number of employees derived from registered new tracked?
☐ Yes
businesses and business renewals ________________
☐ No

7 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

[END OF BUSINESS-FRIENDLINESS & COMPETITIVENESS]

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)

20
 Department of the Interior and Local Government Form CM 3.6
Assessment for the Seal of Good Local Governance Environmental Management
CY 2019

Seal of Good Local Governance – REGIONAL ASSESSMENT

Form CM 3.6 Environmental Management

City/Municipality of : __________________________________ Income Class :

Province : __________________________________ Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the C/MLGOO 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 OR PFP.

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 On open and/or controlled dumpsite in the LGU No operating
dumpsite per
2.1(N) No operating open/controlled dumpsite based on NSWMC list NSWMC?
☐ Yes
☐ Yes
☐ No
☐ No
Or: [CONSIDERATION]
2.2 Open/controlled dumpsite is closed: (i) Closed dumpsite
☐ Yes; per DENR-EMB Regional Office Certification since: _________________ (per EMB RO closed
in CY 2018) + (ii)
☐ No; currently operating approved or
currently drafting
2.3 Status of the LGU’s Safe Closure and Rehabilitation Plan (SCRP): SCRP + (iii) access to
☐ (N) Approved; Date of approval: _________________________ sanitary landfill?
☐ Yes
Percent-completion of plan: _____% ☐ No
☐ Currently drafting with DENR technical assistance; date letter of LGU
request was received: : _____________________
☐ No approved plan yet

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

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

3(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]
LGU-NGA Data Discrepancy Check (tick as appropriate): Plan is already
☐ Data differ; included in the accomplished Change Request Form submitted to
☐ No data discrepancy NSWMC?
☐ Yes
☐ No

21
 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 The LGU has a Materials Recovery Facility -- storage for recyclable materials that is: Has access to MRF
☐ LGU-managed MRF or similar facility or similar facility?
☐ Yes
☐ Through a partnership with similar entity e.g., junkshop
☐ No
☐ No MRF yet

5 LGU’s facility for final disposal (based on accomplished Form CM 2M: Environment and Natural Has own SLF or
Resources Office): access to SLF thru
MOA?
5.1 Sanitary landfill (SLF)as means of final disposal ☐ Yes
☐ (N) LGU’s own SLF ☐ No

☐ Access thru partner-LGU’s SLF Or: [CONSIDERATION]

☐ Access thru private company’s SLF operates
☐ Temporary Residual Containment Area (RCA) temporary RCA +
☐ Ongoing construction of LGU’s own SLF ongoing
☐ No access to sanitary landfill construction of
SLF?
5.2 Other means of final disposal ☐ Yes
☐ No
☐ Technology that is officially recognized by DENR-NSWMC as an
alternative to SLF. Please indicate said means:
_________________________________
☐ No other means of final disposal

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

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

[END OF ENVIRONMENTAL MANAGEMENT]

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)

22
 Department of the Interior and Local Government Form CM 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 CM 3.7 Tourism, Culture and the Arts

City/Municipality of : Income Class :

Province : Region :
INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.
For the RAT Members:
(1) Based on your thorough review of documents provided by the C/MLGOO 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 OR PFP.

Column A Column B
Required Data Processing of
results
TOURISM DEVELOPMENT
LGU Tourism Profile: Please tick available condition (based on accomplished Form CM 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 permanent officer;
CM 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 CM 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

23
 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)

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