Department of the Interior and Local Government Form 1.

1: ALL INDICATORS
Assessment for the Seal of Good Local Governance
CY 2015-2016

THIS IS NOT THE FIELD-TESTING FORM (PLEASE REFER TO FORM 1.2 FOR PROVINCES
OR 1.3 FOR CITIES/MUNICIPALITIES). THIS IS ONLY FOR THE APPRECIATION OF ALL ON
THE LIST OF PROPOSED INDICATORS FOR 2015-2016.YOU MAY ALSO PROVIDE YOUR
INPUTS OR COMMENTS ON THIS LONG LIST.

Means of
Indicator Verified Data
Verification
(A) (B) (C)
I. Good Financial Housekeeping - An LGU that exhibits compliance with accounting and auditing standards, rules and regulations,
as well as , compliance with the Full Disclosure Policy of Local Budget and Finances, Bids and Public Offering, and exerts efforts
towards a sound management of finances
1 2014 COA Audit Opinion Unqualified Qualified Adverse Disclaimer 2014 Audit opinion
rendered by COA as
contained in the Annual
Audit Report

2 Compliance with the Full Disclosure Policy Full Partial Non-Compliance

2.1 Bid and financial documents posted in Full Partial None Certification from
three conspicuos places Regional Assessment
Team
2.2 Bids and financial documents posted in the Full Partial None Certification from the
Full Disclosure Policy Portal Policy Compliance
Monitoring Division,
BLGS-DILG

3 Accurate and timely submission of 2014 On or before March 31, 2015 Beyond March 31, 2015 Certified data from
Statement of Receipts and Expenditures to DOF-BLGF
DOF-BLGF

4 Local Collection Growth Certified data from

DOF-BLGF
%
Tax Revenue
Non-Tax Revenue %

5 Collection Efficiency Rate for GSIS payments % Certified data from

GSIS-CO

II. Disaster-Preparedness: An LGU that shows preparedness for disastersas evident in the structures, plans and systems it
established that may help in anticipating, managing and recovering from the negative impacts of disasters.
6 The LGU is a 2014 National Gawad KALASAG Yes ` No Certified list form DND-
Awardee for Best LDRRMCs or Hall of Fame OCD
Awardee

Hazard assessment, planning and budgeting

7 The LGU has the following plans: PDPFP or CLUP PDPFP or any of the other plans is
+ any of the CLUP only present
other plans

7.1 Provincial Development and Physical Yes No Provincial Development

Framework Plan that is approved by the and Physical
Governor, reviewed by the Provincial Land Framework Plan
Use Committee and approved by the local
sanggunian (provinces)

7.2 Updated Comprehensive Land Use Plan Yes No (1) Certified data from
and Zoning Ordinance (cities and HLURB on CLUP; (2)
municipalities) Zoning Ordinance

7.3 Local Disaster Risk Reduction and Yes No (1)LDRRM Plan; (2)
Management Plan monitoring and audit
If yes, does it include a mechanism for monitoring and auditing the report of LDRRM fund
allocation and utilization of the LDRMM Fund?
Yes No
7.4 Contingency Plan Yes No Contingency Plan

7.5 Local Climate Change Action Plan Yes No Local Climate Change
Action Plan
Organizing
8 The LGU has an LDRRM Operations Center Permanent Temporary None Supporting photos

9 The LDRRM Officer occupies a plantilla position Yes ` No (1) List of filled-up
plantilla positions from
the HRMO; (2)
Certificate of
Appointment from the
LDRMM Officer or
HRMO

10 With executive order or equivalent issuance Yes ` No 1) Executive order or

stating composition of the LDRRMC similar issuance
stating organization
and composition of the
LDRRMC, (2) Minutes of
the meetings
 Means of
Indicator Verified Data
Verification
With executive order( or 1) Executive order or
A )equivalent issuance (B) (C)
stating composition of the LDRRMC similar issuance
If yes, does it indicate name and organization of CSO stating organization
representative? and composition of the
LDRRMC, (2) Minutes of
Yes No the meetings

11 With executive order or equivalent issuance on Yes ` No Executive order or

preemptive and forced evacuation equivalent issuance on
preemptive and forced
evacuation

12 With executive order or equivalent issuance Yes ` No Executive order or

establishing an Incident Command System similar issuance
establishing an Incident
Command System

Operational Readiness
13 The LGU has installed functional early warning Yes Partial No
system (EWS)

13.1 With markers installed in hazard areas Yes No Supporting photos

(e.g. coasts, flood-prone areas, landslide
areas, areas within fault lines) Please state location of markers:
___________________________________________________________
13.2 With audible, early, wide warning and Yes No Supporting photos
alarm system

13.3 With at least one automated rain gauge Yes No Supporting photos
installed to measure amount of rainfall or
precipitation received for a particular Please state location of rain gauge:
period of time, OR ___________________________________________________________

13.4 With indigenous technology proven and Yes No Supporting photos

tested by the community that can
measure amount of rainfall or precipitation Please state name and location of indigenous technology:
received for a particular period of time ___________________________________________________________

13.5 Information on early warning systems Yes No Supporting photos

(EWS) are posted in conspicuous places
within the community

14 Search and Rescue or Emergency Response

Teams

14.1 Equipped with: Yes Partial No Supporting photos

14.1.1 Vehicle (either boat or van Yes No
depending on location)

14.1.2 Water rescue kit (at the minimum Yes No

rope, life jacket, flotation ring or
alternate)
14.1.3 Extrication Kit (at the minimum: Yes No
spine board, shovel or alternate
digging device)

14.1.4 Personal Protective Equipment (at Yes No

the minimum: helmet, goggles,
work gloves, boots)

14.1.5 First aid kit Yes No

14.1.6 Emergency medical kit Yes No
14.2 Trained on: Yes Partial No (1) Supporting photos;
(2) Post Activity Report
14.2.1 Flood/swift water search and Yes No
rescue

14.2.2 Basic life support (first aid) Yes No

15 The LGU has a system of stockpiling supplies of Yes ` No (1) Supporting photos;
goods and medicines or has entered into a or (2) Copy of
memorandum of agreement with suppliers Memorandum of
Agreement with
Suppliers

16 Evacuation center management

16.1 Evacuation centers identified Yes ` No (1) Supporting photos;
(2) list of evacuation
16.2 Have at least one water purifying machine Yes ` No centers; (3) list of
in every evacuation center available and working
equipment

16.3 With Evacuation Center Guide (ECG) With ECG that meets all With ECG that No ECG Copy of Evacuation
criteria partially meets all Center Guide
criteria

16.3.1 Written in local dialect Yes No

16.3.2 With Evacuation Center Map Yes No
16.3.3 Shows Room assignment per Yes No
family
 Means of
Indicator Verified Data
Verification
(A) (B) (C)
16.3.4 Shows services and facilities (e.g. Yes No
toilet, medical services, relief
area, registration system)

17 Percentage of barangays with Evacuation Guide Certified List of

%
(cities and municipalities) barangays with
Evacuation Guides

III. Social Protection - An LGU that is sensitive to the needs of the vulnerable sectors like women, children, senior citizens,
indigenous peoples and persons with disabilities (PWDs), among others.
Access to Justice
18 With LGU-managed Youth Home, Bahay Pag-asa Yes No Certified List of
or similar care-facility for the vulnerable sectors accredited care
e.g. children, women, PWD or senior citizen facilities from DSWD-
(provinces and highly urbanized cities) CO

19 With LGU mechanism for handling cases filed in Yes No Executive order or
Barangay-Violence Against Women and their similar issuance
Children (VAWC) desks or similar within its
jurisdiction (cities and municipalities)

20 Percentage of barangays which have submitted Quarterly status report

%
their 2015 1st Quarter VAWC Quarterly Reports of VAWC desks
to the LSWDO (cities and municipalities) provided to the LSDWO

Access to Basic Health Services

21 LGU-run hospital is accredited by Philhealth for Yes No Certified List of
2014 (provinces) accredited facilities
from PhilHealth-CO

22 Main health facility or rural health unit is For Cities:
accredited by Philhealth in 2014 for the accredited in all three
following (cities and municipalities):
accredited in at least one
no accreditation
For Municipalities:
accredited in MCP and any of
the two
not accredited in MCP but
accredited in any of the two
no accreditation

22.1 Primary health care services (PCB) Yes No Yes No List of accredited
facilities from
PhilHealth-CO
22.2 Maternal health care services (MCP) Yes No Yes No

22.3 Tuberculosis detection and treatment Yes No Yes No

services (TB-DOTS)

23 With at least one LGU-run pharmacy accredited Yes No Certified List of

by Philhealth (for provinces) accredited pharmacies
from PhilHealth-CO
Support to Basic Education
24 Local School Board Plan for 2014 is aligned with Yes No Certified Form 4
the School Improvement Plan

25 Completion Rate of 2014 Local School Board Certified Form 4

%
Plan

26 With daycare center or supervised neighborhood Yes No (1) Executive order or

play (cities and municipalities) similar issuance on the
If yes, does the daycare center have DSWD accreditation? creation of a daycare
Yes No center, (2) supporting
photo, (3) accreditation
certificate from DSWD

Privilege access for PWDs, Senior Citizens, and Pregnant Women

27 With designated express or courtesy lanes for present in all three areas not present in all three areas
PWDs, and senior citizens on LGU frontline
services provided by the: (cities and
municipalities only)

27.1 Business Processing and Licensing Office Yes No Supporting photos

27.2 Rural Health Unit Yes No

27.3 Civil Registry Yes No
28 Complied with the Accessibility Law Yes Partial No

28.1 Has a ramp with handrails on both sides, Yes No Certified Form 3A and
which is located at the entrance and exit 3B
If "Yes", is it compliant with prescribed specifications?
of the provincial capitol, city hall or
municipal hall Yes Partial No

28.2 Has a ramp with handrails on both sides, Yes No

which is located at the entrance and exit
If "Yes", is it compliant with prescribed specifications?
of the province-run hospital, city hospital
or main RHU
 Means of
Has a ramp Indicator
with handrails on both sides, Verified Data
Verification
which is located at the entrance and exit
(A) (B) (C)
of the province-run hospital, city hospital
or main RHU Yes Partial No

28.3 Has a toilet with grab bars in the provincial Yes No

capitol, city hall, municipal hall
If "Yes", is it compliant with prescribed specifications?
Yes Partial No
28.4 Has a toilet with grab bars in the province- Yes No
run hospital, city hospital or main RHU
If "Yes", is it compliant with prescribed specifications?
Yes Partial No
Social Welfare Services
29 With a registered local social worker in the Local Yes No Valid PRC ID for
Social Welfare and Development Office practice of profession
as social worker

30 With fully functional Local Social Work and Yes No Certified list of fully
Development Office (for 2016) functional LSWDO from
the DSWD-CO
31 The LGU implemented programs in each of the Implemented Implemented in some Did not Certified Form 5
sectors relative to social protection in all sectors sectors implement in any
of the sectors

32 With installed Persons with Disability Affairs Yes No Executive Order or

Office or designated focal person who performs similar issuance, and
the functions of the PDAO for 4th-6th Class supporting photos of
Municipalities (for 2016) the office

33 PWDs are issued with PWD identification cards Yes No Certified List of PWDs
(IDs) to accord them with special privileges and issued with IDs
incentives (cities and municipalities)(for 2016)

34 With Annual State of Children's Report Yes No (1) Copy of the Annual
State of Children
Report from the LSWDO
or Office of the LCE

35 With Local Code for Children Yes No (1) Copy of the Local
Code for Children from
the Office of the
Sanggunian

36 With Local Shelter Plan adopted by the Yes No (1) Copy of the Local
Sanggunian (for cities only) Shelter Plan from the
Office of the
Sanggunian

Representation of the sectors in local special bodies

37 Representatives of Indigenous Peoples in the Yes No Not applicable (No IP) "Negative" List will be
Sanggunian are accorded with the same provided by the NCIP,
privilege and emoluments as that of a regular photo of workstation,
Sanggunian member (i.e., compensation, proof of compensation,
minutes of the
workstation, and notice of meetings)
meetings

38 With at least three CSO representatives in the Yes No (1) Executive Order or
Local Development Council similar issuance
stating names of
members of the LDC
including CSO
representatives; (2)
Minutes of the
Meetings
IV. Business-Friendliness and Competitiveness - An LGU that encourages investment and employment
39 Ranked among the top 50 of the Yes ` No (1)Certified List of
Competitiveness Index of the National Competitiveness Index
Competitiveness Council*, OR 2014 Finalist of Top 50 from NCC, or (2)
the PCCIs Most Business-Friendly LGUs Award Certified List of 2014
Finalist of Most
Business-Friendly LGUs
Award from PCCI

40 With office or a designated officer for local Yes ` No Supporting photos;

economic and investment promotion Ordinance or order
designtating LEIPO

41 With an updated Citizen's Charter for securing a Yes ` No (1) Supporting photos;
permit for new business and business renewal (2) Ordinance in
If yes, does it indicate that application has five steps or less? support of Citizen's
(cities and municipalities)
` Yes ` No Charter

42 Business or mayor's permit for new businesses Yes ` No Certified Form 6

is released within five days from the day it was
applied (cities and municipalities)

43 Business or mayor's permit for business Yes ` No Certified Form 6

renewals is released within the day it was
applied (cities and municipalities)

44 With Business One-Stop-shop (cities and Yes ` No Supporting photos

municipalities)
 Means of
Indicator Verified Data
Verification
(A) (B) (C)
45 With Local Investment Incentive Code Yes ` No Copy of Local
Investment Incentive
Code
46 With online business processing and licensing Yes ` No Copy of at least one e-
system (1st -3rd class cities) business permit filed
and issued
47 With a system for tracking and summarizing Yes ` No Copy of printed
economic data (i.e. number of new business, economic data from
If yes, is the system for tracking and summarizing economic data computerized database
business renewals) (cities and municipalities)
computerized? ` Yes ` No

48 With at least one program or service in support Yes ` No Copy of

of micro, small and medium enterprises accomplishment report
from LEIPO

V. Peace and Order - An LGU that shows considerable efforts in maintaining peace and order in the community
49 Percentage implementation of Local Anti- % Certified Form 7
Criminality Action Plan for 2014 (whether a
separate plan or embodied in the Integrated
Area Community Public Safety Plan or Local
Peace and Order, and Public Safety Plan)

50 Percentage utilization of fund allocated for the % Certified Form 7

implementation of the Local Anti-Criminality
Action Plan for 2014 (whether a separate plan
or embodied in the Integrated Area Community
Public Safety Plan or Local Peace and Order, and
Public Safety Plan)

51 With logistical or financial support provided to Yes ` No Certified Form 7

local police station

52 Local Peace and Order Council convened every Yes ` No Minutes of the Quartery
quarter Meetings available for
the LPOC Secretariat
53 The LGU completed at least 3 joint LGU-PNP Yes ` 1 or 2 No Certified Form 7
activities contained in the LACAP for 2014
(whether a separate plan or embodied in the
Integrated Area Community Public Safety Plan or
Local Peace and Order, and Public Safety Plan)
(provinces)

54 With executive order or similar issuance in the Yes ` No Copy of the order of
the organization and mobilization of Barangay the resolution
Peace and Action Teams (BPATS) (cities and organizing and
municipalities) mobilizing BPATS

55 With executive order or similar issuance Yes ` No Copy of the ordinance

intended to prevent, suppress, and impose relative to the
appropriate penalties for drug addiction, prevention,
maintenance of drug dens, and drug pushing suppression and
imposition of penalties
(cities and municipalities)
for drug abuse-related
issues
56 With executive order or similar issuance Yes ` No Copy of the ordinance
prescribing the installation of closed circuit requiring installation of
televisions (CCTVs) as a requirement for the CCTV for the isssuance
issuance of business permits (cities) of business permit

VI. Environmental Management- AN LGU that demonstrates substantial efforts in safeguarding the integrity of the environment
57 With 10-year Solid Waste Management Plan Yes ` No 1) Ordinance adopting
approved by NSWMC, and adopted by the the approved 10-year
Sanggunian If yes, has the LGU allocated funds for the implemenation of the SWM Plan; 2) Copy of
SWM Plan? approved budgetary
` Yes ` No
allocation

58 The LGU has implemented segregation of solid For Provinces: For Cities and Municipalities: Supporting photos
wastes in local government buildings and Provincial Capitol Public market
facilities
Province-run hospital Public School
City or Municipal Hall

59 With materials recovery facility (MRF), or an Yes ` No Supporting photos or

existing partnership with similar entity (cities Memorandum of
and municipalities) Agreement

60 With access to sanitary landfill or alternative Yes ` No Supporting photos or

technology to properly dispose residual waste Memorandum of
If yes, what is the final disposal facility? Agreement
(cities and municipalities)
Sanitary landfill
Alternative technology:
Biomass technology
Co-processing
Mechanical-biological treatment (MBT)
Others (Please specify:___________________________)
 Department of the Interior and Local Government Form 1.2: Field Test Form - Prov
Assessment for the Seal of Good Local Governance Field-Testing Purposes Only
CY 2015-2016

Province: Date:
Region :

INSTRUCTIONS:
1. This form is for the purpose of testing the understandibility and measurability of, and availability of data for the proposed new indicators for the
implementation of SGLG for CYs 2015 and 2016. It only contains those that need to be supplied with data at the local level. (The numbers are
intentionally not sequential. The missing numbers correspond to the other indicators to be supplied with data from NGAs or the indicators tthe indicators
that are not to be ugraded.
2. Field-testing is to be conducted by the LGPMS-SGLG Provincial Focal Person or Provincial Technical Staff.
3. Column A (Indicator) enumerates the critieria to be used for each of the core and essential areas. Column B (Verified Data) are the lists of possible
answers which are to be based on actual data from observations, documentary review and/or on-site inspection during the data collection. Column C
(Means of Verification) enumerates the list of documentary requirement(s) per indicator.
4. Provide the LGPMD-BLGS feedback on the issues and concerns encountered during the field-testing of this Form.

Means of
Indicator Verified Data
Verification
I. Good Financial Housekeeping - An LGU that exhibits compliance with accounting and auditing standards, rules and
regulations, as well as , compliance with the Full Disclosure Policy of Local Budget and Finances, Bids and Public Offering, and
exerts efforts towards a sound management of finances

II. Disaster-Preparedness: An LGU that shows preparedness for disastersas evident in the structures, plans and systems it
established that may help in anticipating, managing and recovering from the negative impacts of disasters.
Hazard assessment, planning and budgeting
7 The LGU has the following plans: PDPFP + any PDPFP any of the other plans is
of the other only present
plans

7.1 With Provincial Development and Physical Yes No Provincial Development

Framework Plan that is approved by the and Physical
Governor, reviewed by the Provincial Land Framework Plan
Use Committee and approved by the local
sanggunian

7.2 With Local Disaster Risk Reduction and Yes No (1)LDRRM Plan; (2)
Management Plan monitoring and audit
If yes, does it include a mechanism for monitoring and auditing report of LDRRM fund
the
allocation and utilization of the LDRMM Fund?
Yes No
7.3 With Contingency Plan Yes No Contingency Plan

7.4 With Local Climate Change Action Plan Yes No Local Climate Change
Action Plan
Organizing
8 The LGU has an LDRRM Operations Center Permanent Temporary None Supporting photos

9 The LDRRM Officer occupies a plantilla position Yes ` No (1) List of filled-up
plantilla positions from
the HRMO; (2)
Certificate of
Appointment from the
LDRMM Officer or
HRMO

10 With executive order or equivalent issuance Yes ` No 1) Executive order or

stating composition of the LDRRMC similar issuance
If yes, does it indicate name and organization of CSO stating organization
representative? and composition of the
LDRRMC, (2) Minutes of
Yes No the meetings

11 With executive order or equivalent issuance on Yes ` No Executive order or

preemptive and forced evacuation equivalent issuance on
preemptive and forced
evacuation

12 With executive order or equivalent issuance Yes ` No Executive order or

establishing an Incident Command System similar issuance
establishing an Incident
Command System

Operational Readiness
13 The LGU has installed functional early warning Yes Partial No
system (EWS)

13.1 With markers installed in hazard areas Yes No Supporting photos

(e.g. coasts, flood-prone areas, landslide
areas, areas within fault lines)
 Means of
With markers installed in hazard areas
Indicator Verified Data
Verification
(e.g. coasts, flood-prone areas, landslide
areas, areas within fault lines) Please state location of markers:
___________________________________________________________
13.2 With audible, early, wide warning and Yes No Supporting photos
alarm system

13.3 With at least one automated rain gauge Yes No Supporting photos
installed to measure amount of rainfall or
precipitation received for a particular Please state location of rain gauge:
period of time, OR ___________________________________________________________

13.4 With indigenous technology proven and Yes No Supporting photos

tested by the community that can
measure amount of rainfall or precipitation Please state name and location of indigenous technology:
received for a particular period of time ___________________________________________________________

13.5 Information on early warning systems Yes No Supporting photos

(EWS) are posted in conspicuous places
within the community

14 Search and Rescue or Emergency Response

Teams

14.1 Equipped with: Yes Partial No Supporting photos

14.1.1 Vehicle (either boat or van Yes No
depending on location)

14.1.2 Water rescue kit (at the minimum Yes No

rope, life jacket, flotation ring or
alternate)
14.1.3 Extrication Kit (at the minimum: Yes No
spine board, shovel or alternate
digging device)

14.1.4 Personal Protective Equipment (at Yes No

the minimum: helmet, goggles,
work gloves, boots)

14.1.5 First aid kit Yes No

14.1.6 Emergency medical kit Yes No
14.2 Trained on: Yes Partial No (1) Supporting photos;
(2) Post Activity Report
14.2.1 Flood/swift water search and Yes No
rescue

14.2.2 Basic life support (first aid) Yes No

15 The LGU has a system of stockpiling supplies of Yes ` No (1) Supporting photos;
goods and medicines or has entered into a or (2) Copy of
memorandum of agreement with suppliers Memorandum of
Agreement with
Suppliers

16 Evacuation center management

16.1 Evacuation centers identified Yes ` No (1) Supporting photos;
(2) list of evacuation
16.2 Have at least one water purifying machine Yes ` No centers; (3) list of
in every evacuation center available and working
equipment

16.3 With Evacuation Center Guide (ECG) With ECG that meets all With ECG that No ECG Copy of Evacuation
criteria partially meets all Center Guide
criteria

16.3.1 Written in local dialect Yes No

16.3.2 With Evacuation Center Map Yes No
16.3.3 Shows Room assignment per Yes No
family
16.3.4 Shows services and facilities (e.g. Yes No
toilet, medical services, relief
area, registration system)

III. Social Protection - An LGU that is sensitive to the needs of the vulnerable sectors like women, children, senior citizens,
indigenous peoples and persons with disabilities (PWDs), among others.
Access to Justice

Access to Basic Health Services

Support to Basic Education

21 Completion Rate of 2014 Local School Board Certified Form 4
%
Plan
 Means of
Indicator Verified Data
Verification
 Means of
Indicator Verified Data
Verification
Privilege access for PWDs, Senior Citizens, and Pregnant Women
22 Complied with the Accessibility Law Yes Partial No

22.1 Has a ramp with handrails on both sides, Yes No Certified Form 3A and
which is located at the entrance and exit 3B
If "Yes", is it compliant with prescribed specifications?
of the provincial capitol
Yes Partial No
22.2 Has a ramp with handrails on both sides, Yes No
which is located at the entrance and exit
If "Yes", is it compliant with prescribed specifications?
of the province-run hospital
Yes Partial No
22.3 Has a toilet with grab bars in the provincial Yes No
capitol
If "Yes", is it compliant with prescribed specifications?
22.4 Has a toilet with grab bars in the province- Yes No
run hospital
If "Yes", is it compliant with prescribed specifications?
Yes Partial No
Social Welfare Services
23 With a registered local social worker in the Local Yes No Valid PRC ID for
Social Welfare and Development Office practice of profession
as social worker

25 The LGU implemented programs in each of the Implemented Implemented in some Did not Certified Form 5
sectors relative to social protection in all sectors sectors implement in
any of the
sectors

26 With installed Persons with Disability Affairs Yes No Executive Order or

Office similar issuance, and
supporting photos of
the office

27 With Annual State of Children's Report Yes No (1) Copy of the Annual
State of Children
Report from the LSWDO
or Office of the LCE

28 With Local Code for Children Yes No (1) Copy of the Local
Code for Children from
the Office of the
Sanggunian

Representation of the sectors in local special bodies

29 Representatives of Indigenous Peoples in the Yes No Not applicable (No IP) "Negative" List will be
Sanggunian are accorded with the same provided by the NCIP,
privilege and emoluments as that of a regular photo of workstation,
Sanggunian member (i.e., compensation, proof of compensation,
minutes of the
workstation, and notice of meetings)
meetings

30 With at least three CSO representatives in the Yes No (1) Executive Order or
Local Development Council similar issuance
stating names of
members of the LDC
including CSO
representatives; (2)
Minutes of the
Meetings
IV. Business-Friendliness and Competitiveness - An LGU that encourages investment and employment
33 With Local Investment Incentive Code Yes ` No Copy of Local
Investment Incentive
Code
34 With at least one program or service in support Yes ` No Copy of
of micro, small and medium enterprises accomplishment report
from LEIPO

V. Peace and Order - An LGU that shows considerable efforts in maintaining peace and order in the community
35 Percentage implementation of Local Anti- % Certified Form 7
Criminality Action Plan for 2014 (whether a
separate plan or embodied in the Integrated
Area Community Public Safety Plan or Local
Peace and Order, and Public Safety Plan)

36 Percentage utilization of fund allocated for the % Certified Form 7

implementation of the Local Anti-Criminality
Action Plan for 2014 (whether a separate plan
or embodied in the Integrated Area Community
Public Safety Plan or Local Peace and Order, and
Public Safety Plan)
 Means of
Indicator Verified Data
Verification
38 Local Peace and Order Council convened every Yes ` No Minutes of the Quartery
quarter Meetings available
from the LPOC
Secretariat

39 The LGU completed at least 3 joint LGU-PNP Yes ` 1 or 2 No Certified Form 7

activities contained in the LACAP for 2014
(whether a separate plan or embodied in the
Integrated Area Community Public Safety Plan or
Local Peace and Order, and Public Safety Plan)

VI. Environmental Management- AN LGU that demonstrates substantial efforts in safeguarding the integrity of the
environment
40 With 10-year Solid Waste Management Plan Yes ` No 1) Ordinance adopting
approved by NSWMC, and adopted by the the approved 10-year
Sanggunian If yes, has the LGU allocated funds for the implemenation of the SWM Plan; 2) Copy of
SWM Plan? approved budgetary
` Yes ` No
allocation

41 The LGU has implemented segregation of solid For Provinces: For Cities and Municipalities: Supporting photos
wastes in local government buildings and Provincial Capitol Public market
facilities
Province-run hospital Public School
City or Municipal Hall

Accomplished by:

Signature over Printed Name of LGPMS PFP or

Provincial Technical Staff
 Department of the Interior and Local Government Form 1.3: Field Test Form - CM
Assessment for the Seal of Good Local Governance Field-Testing Purposes Only
CY 2015-2016

City or Municipality of : Alubijid Region: 10

Province: Misamis Oriental Date: June 26, 2015

INSTRUCTIONS:
1. This form is for the purpose of testing the understandibility and measurability of, and availability of data for the proposed new indicators for the
implementation of SGLG for CYs 2015 and 2016. It only contains those that need to be supplied with data at the local level. (The numbers are
intentionally not sequential. The missing numbers correspond to the other indicators to be supplied with data from NGAs or the indicators that are not to
be ugraded.
2. Field-testing is to be conducted by the C/MLGOO for cities and municipalities.
3. Column A (Indicator) enumerates the critieria to be used for each of the core and essential areas. Column B (Verified Data) are the lists of possible
answers which are to be based on actual data from observations, documentary review and/or on-site inspection during the data collection. Column C
(Means of Verification) enumerates the list of documentary requirement(s) per indicator.
4. Provide the LGPMD-BLGS feedback on the issues and concerns encountered during the field-testing of this Form.

Means of
Indicator Verified Data
Verification
(A) (B) (C)

I. Good Financial Housekeeping - An LGU that exhibits compliance with accounting and auditing standards, rules and
regulations, as well as , compliance with the Full Disclosure Policy of Local Budget and Finances, Bids and Public Offering, and
exerts efforts towards a sound management of finances

II. Disaster-Preparedness: An LGU that shows preparedness for disastersas evident in the structures, plans and systems it
established that may help in anticipating, managing and recovering from the negative impacts of disasters.
Hazard assessment, planning and budgeting
7 The LGU has the following plans: CLUP + any of CLUP only / any of the other plans is
the other plans present

7.1 Updated Comprehensive Land Use Plan / Yes No (1) Certified data from
and Zoning Ordinance (cities and HLURB on CLUP; (2)
municipalities) Zoning Ordinance

7.2 Local Disaster Risk Reduction and / Yes No (1)LDRRM Plan; (2)
Management Plan monitoring and audit
If yes, does it include a mechanism for monitoring and auditing report of LDRRM fund
the
allocation and utilization of the LDRMM Fund?
/ Yes No
7.3 Contingency Plan / Yes No Contingency Plan

7.4 Local Climate Change Action Plan Yes / No Local Climate Change
Action Plan
Organizing
8 The LGU has an LDRRM Operations Center / Permanent Temporary None Supporting photos

9 The LDRRM Officer occupies a plantilla position / Yes ` No (1) List of filled-up
plantilla positions from
the HRMO; (2)
Certificate of
Appointment from the
LDRMM Officer or
HRMO

10 With executive order or equivalent issuance / Yes ` No 1) Executive order or

stating composition of the LDRRMC similar issuance
If yes, does it indicate name and organization of CSO stating organization
representative? and composition of the
LDRRMC, (2) Minutes of
/ Yes No the meetings

11 With executive order or equivalent issuance on / Yes ` No Executive order or

preemptive and forced evacuation equivalent issuance on
preemptive and forced
evacuation

12 With executive order or equivalent issuance Yes / No Executive order or

establishing an Incident Command System similar issuance
establishing an Incident
Command System

Operational Readiness
13 The LGU has installed functional early warning / Yes Partial No
system (EWS)

13.1 With markers installed in hazard areas / Yes No Supporting photos

(e.g. coasts, flood-prone areas, landslide
areas, areas within fault lines) Please state location of markers: AlubijidBridge/River

13.2 With audible, early, wide warning and / Yes No Supporting photos
alarm system

13.3 With at least one automated rain gauge / Yes No Supporting photos
installed to measure amount of rainfall or
precipitation received for a particular Please state location of rain gauge: Barangay Benigwayan
period of time, OR
 Means of
Indicator Verified Data
Verification
(A) (B) (C)
13.4 With indigenous technology proven and / Yes No Supporting photos
tested by the community that can
measure amount of rainfall or precipitation Please state name and location of indigenous technology:
received for a particular period of time ___________________________________________________________

13.5 Information on early warning systems Yes / No Supporting photos

(EWS) are posted in conspicuous places
within the community

14 Search and Rescue or Emergency Response

Teams

14.1 Equipped with: / Yes Partial No Supporting photos

14.1.1 Vehicle (either boat or van / Yes No
depending on location)

14.1.2 Water rescue kit (at the minimum / Yes No

rope, life jacket, flotation ring or
alternate)
14.1.3 Extrication Kit (at the minimum: / Yes No
spine board, shovel or alternate
digging device)

14.1.4 Personal Protective Equipment (at / Yes No

the minimum: helmet, goggles,
work gloves, boots)

14.1.5 First aid kit / Yes No

14.1.6 Emergency medical kit / Yes No
14.2 Trained on: Yes Partial No (1) Supporting photos;
(2) Post Activity Report
14.2.1 Flood/swift water search and / Yes No
rescue

14.2.2 Basic life support (first aid) / Yes No

15 The LGU has a system of stockpiling supplies of / Yes ` No (1) Supporting photos;
goods and medicines or has entered into a or (2) Copy of
memorandum of agreement with suppliers Memorandum of
Agreement with
Suppliers

16 Evacuation center management

16.1 Evacuation centers identified / Yes ` No (1) Supporting photos;
(2) list of evacuation
16.2 Have at least one water purifying machine Yes / No centers; (3) list of
in every evacuation center available and working
equipment

16.3 With Evacuation Center Guide (ECG) With ECG that meets all / With ECG that No ECG Copy of Evacuation
criteria partially meets all Center Guide
criteria

16.3.1 Written in local dialect Yes / No

16.3.2 With Evacuation Center Map Yes / No
16.3.3 Shows Room assignment per Yes / No
family
16.3.4 Shows services and facilities (e.g. / Yes No
toilet, medical services, relief
area, registration system)

17 Percentage of barangays with Evacuation Guide Certified List of

0% barangays with
Evacuation Guides

III. Social Protection - An LGU that is sensitive to the needs of the vulnerable sectors like women, children, senior citizens,
indigenous peoples and persons with disabilities (PWDs), among others.
Access to Justice
19 With LGU mechanism for handling cases filed in / Yes No Executive order or
Barangay-Violence Against Women and their similar issuance;
Children (VAWC) desks or similar within its supporting photos
jurisdiction

20 Percentage of barangays which have submitted Quarterly status report

100% of VAWC desks
their 2015 1st Quarter VAWC Quarterly Reports
to the LSWDO provided to the LSDWO

Access to Basic Health Services

Support to Basic Education

23 Completion Rate of 2014 Local School Board 99% Certified Form 4
Plan
24 With daycare center or supervised neighborhood / Yes No (1) Executive order or
play similar issuance on the
If yes, does the daycare center have DSWD accreditation? creation of a daycare
center, (2) supporting
photo, (3) accreditation
certificate from DSWD
 Means of
Indicator
With daycare center or supervised neighborhood Verified Data (1) Executive order or
Verification
play similar issuance on the
(A) (B) creation of( C )
a daycare
/ Yes No center, (2) supporting
photo, (3) accreditation
certificate from DSWD
 Means of
Indicator Verified Data
Verification
(A) (B) (C)
Privilege access for PWDs, Senior Citizens, and Pregnant Women
25 With designated express or courtesy lanes for / present in all three areas not present in all three areas
PWDs, and senior citizens on LGU frontline
services provided by the:

27.1 Business Processing and Licensing Office / Yes No Supporting photos

27.2 Rural Health Unit / Yes No

27.3 Civil Registry / Yes No
26 Complied with the Accessibility Law Yes / Partial No

26.1 Has a ramp with handrails on both sides, Yes / No Certified Form 3A and
which is located at the entrance and exit 3B
If "Yes", is it compliant with prescribed specifications?
of the city hall or municipal hall
Yes Partial No
26.2 Has a ramp with handrails on both sides, Yes / No
which is located at the entrance and exit
If "Yes", is it compliant with prescribed specifications?
of the city hospital or main RHU
Yes Partial No
26.3 Has a toilet with grab bars in the city hall / Yes No
or municipal hall
If "Yes", is it compliant with prescribed specifications?
Yes / Partial No
26.4 Has a toilet with grab bars in the , city Yes / No
hospital or main RHU
If "Yes", is it compliant with prescribed specifications?
Yes Partial No
Social Welfare Services
27 With a registered local social worker in the Local / Yes No Valid PRC ID for
Social Welfare and Development Office practice of profession
as social worker

29 The LGU implemented programs in each of the / Implemented Implemented in some Did not Certified Form 5
sectors relative to social protection in all sectors sectors implement in
any of the
sectors
30 With installed Persons with Disability Affairs / Yes No Executive Order or
Office or designated focal person who performs similar issuance, and
the functions of the PDAO for 4th-6th Class supporting photos of
Municipalities (for 2016) the office

31 PWDs are issued with PWD identification cards / Yes No Certified List of PWDs
(IDs) to accord them with special privileges and issued with IDs
incentives (for 2016)

32 With Annual State of Children's Report Yes / No (1) Copy of the Annual
State of Children
Report from the LSWDO
or Office of the LCE

33 With Local Code for Children Yes / No (1) Copy of the Local
Code for Children from
the Office of the
Sanggunian

34 With Local Shelter Plan adopted by the Yes No (1) Copy of the Local
Sanggunian (for cities only) Shelter Plan from the
Office of the
Sanggunian

Representation of the sectors in local special bodies

35 Representatives of Indigenous Peoples in the Yes No / Not applicable (No IP) "Negative" List will be
Sanggunian are accorded with the same provided by the NCIP,
privilege and emoluments as that of a regular photo of workstation,
Sanggunian member (i.e., compensation, proof of compensation,
minutes of the
workstation, and notice of meetings)
meetings

36 With at least three CSO representatives in the / Yes No (1) Executive Order or
Local Development Council similar issuance
stating names of
members of the LDC
including CSO
representatives; (2)
Minutes of the
Meetings
IV. Business-Friendliness and Competitiveness - An LGU that encourages investment and employment
43 With Local Investment Incentive Code Yes ` No Copy of Local
Investment Incentive
Code
44 With online business processing and licensing Yes / No Copy of at least one e-
system (1st -3rd class cities) business permit filed
and issued
45 With a system for tracking and summarizing / Yes ` No Copy of printed
economic data (i.e. number of new business, economic data from
If yes, is the system for tracking and summarizing economic data computerized database
business renewals) (cities and municipalities)
computerized? ` Yes
\ ` No
 Means of
Indicator Verified Data
Verification
(A) (B) (C)
46 With at least one program or service in support Yes ` No Copy of
of micro, small and medium enterprises x accomplishment report
from LEIPO

V. Peace and Order - An LGU that shows considerable efforts in maintaining peace and order in the community
47 Percentage implementation of Local Anti- 100% Certified Form 7
Criminality Action Plan for 2014 (whether a
separate plan or embodied in the Integrated
Area Community Public Safety Plan or Local
Peace and Order, and Public Safety Plan)

48 Percentage utilization of fund allocated for the Certified Form 7

100%
implementation of the Local Anti-Criminality
Action Plan for 2014 (whether a separate plan
or embodied in the Integrated Area Community
Public Safety Plan or Local Peace and Order, and
Public Safety Plan)

50 Local Peace and Order Council convened every / Yes ` No Minutes of the Quartery
quarter Meetings available
from the LPOC
Secretariat

51 With executive order or similar issuance in the / Yes ` No Copy of the order of
the organization and mobilization of Barangay the resolution
Peace and Action Teams (BPATS) organizing and
mobilizing BPATS

52 With executive order or similar issuance Yes / No Copy of the ordinance

intended to prevent, suppress, and impose relative to the
appropriate penalties for drug addiction, prevention,
maintenance of drug dens, and drug pushing suppression and
imposition of penalties
for drug abuse-related
issues
53 With executive order or similar issuance Yes / No Copy of the ordinance
prescribing the installation of closed circuit requiring installation of
televisions (CCTVs) as a requirement for the CCTV for the isssuance
issuance of business permits (cities) of business permit

VI. Environmental Management- AN LGU that demonstrates substantial efforts in safeguarding the integrity of the
54 With 10-year Solid Waste Management Plan / Yes ` No 1) Ordinance adopting
approved by NSWMC, and adopted by the the approved 10-year
If yes, has the LGU allocated funds for the implemenation of the SWM Plan; 2) Copy of
Sanggunian
SWM Plan? ` Yes approved budgetary
` No
allocation

55 The LGU has implemented segregation of solid For Provinces: For Cities and Municipalities: Supporting photos
wastes in local government buildings and Provincial Capitol Public market
facilities
Province-run hospital / Public School
City or Municipal Hall

Accomplished by:

MARLENE M. PAHUNANG
Signature over Printed Name of C/MLGOO
 Department of the Interior and Local Government Form 2: GFH-FDP-CP
Assessment for the Seal of Good Local Governance NOT TO BE FILLED-UP
CY 2015-2016

Seal of Good Local Governance

FORM 2 Good Financial Housekeeping- FDP Compliance, Posting in Three (3) Conspicuous Places

City or Municipality of : Region :

Province : Date of Inspection :

Specify location of posting:

1. 3.
2.

CERTIFICATION FORM

INSTRUCTIONS:
1. Under the column Area, tick (/) if documents are posted in area(s) 1, 2 and/or 3.
2. Tick (/) Yes if the LGU complied by posting indicated document in THREE locations; otherwise, tick (/) No.
3. Answer Box A by ticking (/) Full if alll 14 documents are complied with, Partial if not all documents are
posted, OR None in case of no posting at all.

Area Complied?
Required Documents for Posting
1 2 3 Yes No
The LGU posted the following documents:
1. 2015 Annual Budget / / / /
2. 2015 Annual Procurement Plan or Procurement List / / / /
3. 2014 Statement of Debt Service / / / /
4. 2014 Annual Gender and Development Accomplishment Report / / / /
5. 2014 Statement of Receipts and Expenditures / / / /
6. 4th Quarter 2014, Statement of Cash Flow / / / /
7. 4th Quarter 2014, Special Education Fund Utilization / / / /
8. 4th Quarter 2014, Trust Fund Utilization / / / /
9. 4th Quarter 2014, Bid Results on Civil Works and Goods and Services / / / /
10. 4th Quarter 2014, 20% Component of IRA Utilization / / / /
11. 4th Quarter 2014, Local DRRM Fund Utilization / / / /
12. 4th Quarter 2014, Unliquidated Cash Advances / / / /
13. 4th Quarter 2014, Manpower Complement / / / /
14. 4th Quarter 2014, Supplemental Procurement Plan / / / /

Box A
Full Partial Non
FDP Compliance, Posting in Three (3) Conspicuous Places
/

Verified and Certified by:

Signature over Printed Name

NOT TO BE FILLED-UP
 Department of the Interior and Local Government Form 3A: SP-AC-R & T
Assessment for the Seal of Good Local Governance Field-Testing Purposes Only
CY 2015-2016

Seal of Good Local Governance

FORM 3A Social Protection - Accessibility Checklist - Ramps and Toilets - Provincial Capitol, City/Municipal Hall

City or Municipality of : Alubijid Region : 10

Province : Misamis Oriental Date of Inspection : June 30, 2015

CERTIFICATION FORM
Accessibility Checklist Based on Batas Pambansa Bilang 334 (Accessibility Law)

INSTRUCTIONS:
1. Tick (/) Yes if the LGU complied with the indicated specification for ramp or toilet; otherwise, tick (/) No.
2. Write additional remarks or notes as may be necessary.
3. Answer Box A by ticking (/) Full if alll specifications are complied with, Partial if not all specifications are satisfied,
OR None in case none are met at all.

Complied? Actual Dimension / Description /

Specification
Yes No Remarks
I. RAMPS
1. Located at/near main entrance / 1st floor; 2nd floor - none
2. Gradient
2.1 Equal or flatter than 1:12
2.2 Steeper than 1:12 /
3. Has handrails on both sides of the ramp / one side only
4. Both handrails have:
4.1 2 levels: 1st level is 0.70 m high; 2nd is 0.90 m
4.2 0.30 m extension each at the start and end /
4.3 Handrail diameter of 30 mm to 50 mm /
4.4 Clearance of 50 mm if wall mounted / not wall mounted
5. Not more than 6.0 m /
6. If longer than 6.0 m, there is 1.5 m landing every
6 m length of ramp
7. Clear width is 1.2 m /
8. Curbs on both sides, 100 mm high /
9. Non-skid flooring / finish /
10. Level area (1.80 m) provided at the start and end
of ramps
11. With signage using the International Symbol of
Access /
II. TOILET
1. Clear dimension of toilet cubicle is 1.70 m x 1.80 m /
2. Permit easy passage if wheelchair (1.50 m turning /
space
3. Door swings out /
4. Clear opening of door is 0.8 m /
5. One fixed grab bar mounted at 0.80 m (measured
from Finish Floor Line to top of grab bar) /
6. One movable grab bar (Outrigger) /
7. Non-skid flooring /
8. Signage: Mounted 1.50 m O.C. from Finish Floor
Line using International Symbol of Access /

Box A
Compliance with the specification of: Full Partial No
Ramps installed in the Provincial Capitol or City/Municipal Hall /
Accessible Toilet in the Provincial Capitol or City/Municipal Hall /

Certified by:

WILFREDO L. ARANETA
 Signature over Printed Name of
Provincial/City/Municipal Engineer
Field-Testing Purposes Only
 Department of the Interior and Local Government Form 3B: SP-AC-Hospital
Assessment for the Seal of Good Local Governance Field-Testing Purposes Only
CY 2015-2016

Seal of Good Local Governance

FORM 3B Social Protection - Accessibility Checklist - Ramps and Toilets - Province-Run Hospital, City Hospital or Main RHU

City or Municipality of : Alubijid Region : 10

Province : Misamis Oriental Date of Inspection : June 26, 2015

CERTIFICATION FORM
Accessibility Checklist Based on Batas Pambansa Bilang 334 (Accessibility Law)

INSTRUCTIONS:
1. Tick (/) Yes if the LGU complied with the indicated specification for ramp or toilet; otherwise, tick (/) No.
2. Write additional remarks or notes as may be necessary.
3. Answer Box A by ticking (/) Full if alll specifications are complied with, Partial if not all specifications are satisfied,
OR None in case none are met at all.

Complied? Actual Dimension / Description /

Specification
Yes No Remarks
I. RAMPS
1. Located at/near main entrance /
2. Gradient
2.1 Equal or flatter than 1:12 /
2.2 Steeper than 1:12
3. Has handrails on both sides of the ramp /
4. Both handrails have:
4.1 2 levels: 1st level is 0.70 m high; 2nd is 0.90 m
4.2 0.30 m extension each at the start and end /
4.3 Handrail diameter of 30 mm to 50 mm /
4.4 Clearance of 50 mm if wall mounted /
5. Not more than 6.0 m /
6. If longer than 6.0 m, there is 1.5 m landing every
6 m length of ramp
7. Clear width is 1.2 m /
8. Curbs on both sides, 100 mm high /
9. Non-skid flooring / finish /
10. Level area (1.80 m) provided at the start and end
of ramps /
11. With signage using the International Symbol of
Access /
II. TOILET
1. Clear dimension of toilet cubicle is 1.70 m x 1.80 m /
2. Permit easy passage if wheelchair (1.50 m turning /
space
3. Door swings out /
4. Clear opening of door is 0.8 m /
5. One fixed grab bar mounted at 0.80 m (measured
from Finish Floor Line to top of grab bar) /
6. One movable grab bar (Outrigger) /
7. Non-skid flooring /
8. Signage: Mounted 1.50 m O.C. from Finish Floor
Line using International Symbol of Access /

Box A
Compliance with the specification of: Full Partial No
Ramps installed in the Province-run hospital, city hospital or main RHU /
Toilet for PWDs in the Province-run hospital, city hospital or main RHU /

Certified by:

WILFREDO L. ARANETA
 Signature over Printed Name of
Provincial/City/Municipal Engineer
 Department of the Interior and Local Government Form 4: SP-Educ
Assessment for the Seal of Good Local Governance Field-Testing Purposes Only
CY 2015-2016

Seal of Good Local Governance

FORM 4 Social Protection - Support to Education

CERTIFICATION

This is to certify that the Local School Board (LSB) Plan for CY 2014 of the Province / City /
Municipality of Alubijid is aligned with the School Improvement Plan of the Department of Education. As a
proof, I affixed my signature in the LSB Plan.

Accordingly, 99% of programs, project and activities of the LSB Plan are completed.

Moreover, the City / Municipality has 30 day care centers or supervised neighborhood play (Please
supply required data).

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued this 30th day of June, 2015 at the Municipality of Alubijid,

Province of Misamis Oriental.

Certified by:

ROIE M. UBAYUBAY
Signature over Printed Name
DepEd Schools Division Superintendent / Designated
Representative of LSB
 Department of the Interior and Local Government Form 5: SP-SP Sec Prog
Assessment for the Seal of Good Local Governance Field-Testing Purposes Only
CY 2015-2016

Seal of Good Local Governance

FORM 2.5 Social Protection- Social Protection Sectoral Programs

City or Municipality of : Alubijid Region : 10

Province : Misamis Oriental Date of Inspection : June 26, 2015

CERTIFICATION FORM

INSTRUCTIONS:
1. Tick (/) Yes if the LGU implemented the indicated Social Protection Program; otherwise, tick (/) No.

2. Answer Box A by ticking (/) Yes if at least one Social Protection Program was implemented for each
of the sector; otherwise , tick (/) No.

Implemented?
Social Protection Sectoral Programs
Yes No
A. Child and Youth Welfare Program
1. Adoption /
2. Foster Care Service /
3. Early Childhood Care and Development Service /
4. Residential Care Services /
5. Community Based Services for Street Children /
6. Community Based Services for Children in Conflict with the Law /
7. Services for Children in Armed Conflict /
8. Drug Abuse Prevention Program /
9. Government Internship Program /
10. Unlad Kabataan Program /
11. Immersion Outreach Program /
12. PYAP Cash for Work /
13. Educational Assistance Program /
14. Livelihood Assistance Program /
B. Women's Welfare Program
1. Self Enhancement Skills Development /
2. Productivity Skills Capacity Building /
3. Community Participation Skills Development /
4. Maternal and Child Care /
5. Rape Crisis Center /
6. Residential Care Facility for Women in Especially Difficult Circumstances /
7. Processing Center for Victims of Trafficking /
8. After Care Services /
C. Persons with Disabilities Welfare Program
1. Disability Prevention Service /
2. Early Detection, Prevention of Disability /
3. Assistance for Physical Restoration Services /
4. Self and Social Enhancement Service /
5. Tuloy Aral Walang Sagabal for Children with Disabilities /
6. After Care and Follow-up Services /
7. Referral Services /
 8. Training and Employment Support Services /
9. Alternative Family Support Services /
10. Community Based Social Vocational Rehabilitation Preparation for Employment Services /
11. Auxilliary Social Services /
12 Foster Home Program for Persons woith Disability /
D. Older Person's Program
1. Social Pension for Indigent Senior Citizens and other special support services /
2. Neighborhood Support Services for Older Persons /
3. Home Care Support Service /
4. Residential Care Service /
5. Special Services for the Elderly /
6. Foster Home Program for Older Persons /
7. Volunteer Resource Service /
E. Family and Community Welfare Program
1. Parent Effectiveness Services /
2. Pre-Marriage Counseling /
3. Marriage Counseling Services /
4. Family Casework /
5. Responsible Parenthood Services /
6. Empowerment and Reaffirmation of Paternal Abilities /
7. Social Services for Solo Parent /
8. Self-Employment Assistance /
9. Program for Deportees /
10. National Family Violence Prevention Program /
11. Social Preparation for People's Participation /
12. Social Welfare Structure Development /
13. Community Volunteers Resource Development /
14. Community Mobilization Service /
15. Assistance in Crisis Situations /
16. International Social Welfare Services for Filipino Nationals /
D. Internally Displaced Persons Welfare Program
1. Food/Cash for Work /
2. Emergency Shelter Assistance /
3. Core Shelter Assistance /
4. Balik Probinsiya /
5. Psycho-social Support /
6. Crisis Intervention /
7. Assistance to individual and family in Crisis Situation /

BOX A
Implemented at least one program in each of the sectors relative to social protection YES NO
A. Child and Youth Welfare /
B. Women's Welfare /
C. Persons with Disabilities Welfare /
D. Older Persons Welfare /
E. Family and Community Welfare /
F. Internally Displaced Persons Welfare /

Certified by:

JESSELITA L. ARMECIN
Signature over Printed Name of Local Social
Welfare and Development Officer
Only
 Department of the Interior and Local Government Form 6: BFC
Assessment for the Seal of Good Local Governance NOT TO BE FILLED-UP
CY 2015-2016

Seal of Good Local Governance

FORM 6 Business-Friendliness and Competitiveness: Business Permit Transaction Samples

City or Municipality of : Region :

Province : Date of Inspection :

INSTRUCTION:
1. Please supply the required information.
2. For the portion on Sample Transactions, tick (/) Yes or No if transaction was done within five (5) days for the
specified new business application, and one (1) day for business renewal application.

Processing time in issuing a business or mayor's permit

NEW BUSINESS PERMITS BUSINESS RENEWAL
Date (Month and Day) with Date (Month and Day)
highest volume of with highest volume of
transaction for business transaction for business
permits permits
Total number of Total Number of
transactions Transactions

Sample Transactions: Sample Transactions:

Within 5 days from Within 1 day from
application to application to
Application No. release? Application No. release?
Yes No Yes No
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10. 10.
11. 11.
12. 12.
13. 13.
14. 14.
15. 15.
16. 16.
17. 17.
18. 18.
19. 19.
20. 20.
(Attach additional pages, if necessary.)

Notes:
For new business: Application filed on Day 1 should be released not later than Day 6.
For busines renewals: If application is filed in the morning, permit I released on the same day; if application is filed in the
afternoon, permit is released on the morning of the following day.
Weekends not
counted.
This form must contain samples for both new business permit and business renewal transaction. If the date with highest
volume only has transaction(s) for business renewals only, record them and select one more date which has transaction(s) for
new business permit; and vice versa.
Verified and Certified by:

Signature over Printed Name

 Department of the Interior and Local Government Form 7: PO
Assessment for the Seal of Good Local Governance Field-Testing Purposes Only
CY 2015-2016

Seal of Good Local Governance

FORM 7 Peace and Order

CERTIFICATION

This is to certify that the Province/City/Municipality of Alubijid, has

undertaken the following:
/
The Governor or Mayor convened, at least once every quarter, the Local Peace and Order
x Council (LPOC) in CY 2014.

/
The LGU has adopted and implemented a Local Anti-Criminality Action Plan for CY 2014
(whether a separate plan or embodied in the Integrated Area Community Public Safety Plan or
Loca Peace and Order, and Public Safety Plan.

/ The LGU has provided logistical or financial support in the form of financial support for
gasoline, intelligence networking etc. (e.g. ammunition, communication, vehicles, police
station, supplies) to the PNP Local Police Office/Station in CY 2014.

The Province has completed, at least three (3), joint Province-PNP activity as contained in the
Local Anti-Criminality Action Plan for CY 2014 (for provinces only).

/ The City or Municipality has supported the organization of the Barangay Peacekeeping Action
Teams, or its equivalent (for cities and municipalities only).

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued this 26th day of June, 2015 at the PNP Police Office/Station,
Alubijid, Misamis Oriental.

Certified by:

P/INSP RUSTICO R GALAGALA

Signature over Printed Name
Chief, Local PNP Office/Station
s Only