A State Agency of the Ministry of Sport and Community Development
THE NATIONAL COMMISSION FOR SELF HELP
LIMITED
Community Infrastructural Development
(CID) Programme Application Form
Head Office: Lassalle Court, 75 Abercromby Street, Port-of-Spain Phone: 612-6274 Fax:
627-8435 South Office: 54 Southern Main Road, Marabella, San Fernando Phone: 652-3044
Tobago Office: 91 Barrington’s Court, Bon Accord, Tobago Phone: 660-7672
FOR OFFICIAL USE
Constituency/Area Code: Project No:
1. PROJECT TYPE(S): (Please tick any of the following)
☐ Road ☐ Retaining Wall ☐ Drainage ☐ Bridge ☐ School ☐ Cultural ☐ Steps
☐ Social ☐ Health ☐ Recreation ☐ Community Centre ☐Other:
2. Name of Group/Organization/Applicant(s):
3. Project Location/Address:
4. (a) Have your group approached any other agency for funding? ☐ Yes ☐ No
(b) If yes, state the name of the funding agency and the amount:
5. Name(s) of Coordinator(s): 1. Contact No.:
2. Contact No.:
6. Brief description of the proposed project:
7. The number of persons benefitting from the project:
8. Gender Mix: (Male) (Female) (Children) (This is mandatory)
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9. Who benefits from this project?
Category Direct Indirect
Men/Boys ☐ ☐
Women/Girls ☐ ☐
Pensioners ☐ ☐
Victims of Domestic Violence ☐ ☐
Socially Displaced ☐ ☐
Unemployed ☐ ☐
Persons with Disabilities ☐ ☐
Persons/Households Living in Poverty ☐ ☐
Persons living with HIV/AIDS ☐ ☐
Ex-Prisoners/Deportees ☐ ☐
Prisoners ☐ ☐
Probationers ☐ ☐
Substance Abusers ☐ ☐
Athletes ☐ ☐
NGO’s ☐ ☐
Other_______________________________________________
10. What community services are available?
☐ Health Centres/Clinic Facility ☐ Community Centre
☐ Recreation Grounds ☐ Religious House (s)
☐ Primary School (s) ☐ Secondary School (s)
☐Community Handicraft/Skill Workshops ☐Other ___________________
11. Living Assessment
Water Supply ☐ None ☐ Truckborne ☐ Stand Pipe ☐ Household
Road Condition ☐ None ☐ Dirt/Gravel ☐ Poorly Paved ☐ Good Condition
Electricity ☐ None ☐ Light Poles ☐ Household
Supply
Housing Quality/Type ☐ Homeless ☐ Wooden ☐ Wooden Flat ☐ Concrete
Shacks Structure
Avg. no. of Houses ☐ Under 10 ☐ 11-30 ☐ 31-50 ☐ Above 51
Avg. size of Household ☐ 2-5 Persons ☐ 6-10 Persons ☐ 10-15 Persons ☐ Above
15 Persons
Unemployment Level ☐ 10- 30 % ☐ 31-50% ☐ 51-75% ☐ 76-99%
Skills Level ☐ Unskilled ☐ Semiskilled/ ☐ Skilled/ ☐ Skilled/
Trade Unemployed Employed
Income Levels ☐ Below ☐ Below ☐ Below ☐ Over
$1500 $2500 $4000 $4001
Family Structures ☐ Single ☐ Single ☐ Both Parents ☐ Relatives
Parent (F) Parent (M)
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Community Commitment Form
We, the residents listed, are aware of the efforts being made to undertake a community self-help project and
we are prepared to support it by way of providing the necessary labour, materials or any other contribution
that will exemplify this.
SIGNATURES OF BENEFITTING COMMUNITY
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FOR OFFICIAL USE
PROJECT OFFICER’S EVALUATION SHEET
1. Does the project meet NCSHL’s criteria and is recommended for approval?
☐Yes ☐ No
2. (a) If no, please state reason(s)
(b) If yes, the labour required is:
☐ Non-Skilled ☐ Semi Skilled ☐ Skilled
3. Do you recommend that a contractor be assigned to assist with the provision of labour and materials?
□ Yes □ No
Project Officer: …………………………………… Date: ……………………
Senior Project Officer: …………………………………… Date: ……………………
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SAFETY ISSUES
1. Was a Safety/ Risk Analysis conducted? ☐ Yes ☐ No
2. What are the identifiable hazards?
(1) _________________________________________________________________________________
(2) _________________________________________________________________________________
(3) _________________________________________________________________________________
(4) _________________________________________________________________________________
3. Was this information communicated to the Community-nominated Coordinator? □ Verbally □ Written
4. Is the Contractor aware of the safety issues? ☐ Yes ☐ No
5. What are your recommended methods of control/prevention?
(1) _________________________________________________________________________________
(2) _________________________________________________________________________________
(3) _________________________________________________________________________________
(4) _________________________________________________________________________________
6. Officer’s Comments on Project Scope
:
__________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
** PLEASE ATTACH DETAILED WORKING DRAWINGS
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