SCHOOL HYGIENE, SANITATION, AND WATER
PROJECT REQUEST FORM
1. Project title:______
2. Requesting school
project location:______
3. Region: ______
4. Zone: ______
5. (Name of District): ______
Students: ______(total) Pre-school ______(total)
Girls: ______Primary school ______(total)
Boys: ______Secondary school _____(total)
Available facilities:
Water: (indicate the most likely options to choose)
Hand Washing: (ask for technique and availability)
Toilets : ______(total) condition:
Urinals: ______(total) condition:
Garbage disposal: (ask for technique and availability)
Health Club: yes/no
6. Required improvements (just a first indication) ______
7. Community size: ______
8. Health clinic available: (if not indicate distance to closest clinic)
9. Available operation and maintenance capacity in community:
10. Summary of available water, sanitation and hygiene-related health statistics for school-age children in the community:
Helminth:
Diarrhea:
Malaria
Anemia:
Etc.
Project Preparation
11. Required facilities:
Water supply, hand wash, sanitation, garbage collection (also give a first indication of technology of preference)
12. Demand for life-skills based hygiene education. Indicate needs for children and community
13. Tentative arrangements for school, parents and community contributions to project development (issues, such as financial contribution, project supervision, provision of unskilled labor, provision of local building materials, etc.)
Conformity with (name of multi-sector project) guidelines for proposal preparation
14. Preparatory community meeting held in which the basic principles, environmental issues and requirements of the school hygiene, sanitation and water project were explained to teachers and parents Yes, on ______/20_____ No ( )
15. School hygiene committee elected Yes, on ______/20_____ No ( )
16. Composition of members: ______men and ______women. Are any of the following positions held by women? If so, indicate which.
17. Chairperson ( ) Name: ______
18. Secretary ( ) Name: ______
19. Treasurer ( ) Name: ______
20. If yes, which ones:
21. Additional comments justifying this project:
22. Application signed by School Hygiene Committee chairperson:
Name: ______
23. Assistance in preparing this proposal has been provided by:
Name: ______
______