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Esmf Assessment Template -Form Fill

Project Information
Q01

Any Sensitive location ?

Q01A

Does the project document contains proforma B ?

Q02

Whether belong to Level 1or 2 as per Proforma B- Control list

Q03

Regulatory List Screening Tool Proforma A

Q04

While preparing the DPR whether the GP has followed the laid out guidelines pertaining to PIM and ESMF ?

Q05

Whether ESMF guidelines has been followed?

Q06

Approval as per laid guidelines in ESMF

Q07

Whether the Compliance report of ESMF available ?

Q08

Whether the following mitigation applied?

Q08_1

Material Source

Q08_2

Natural resource depletion

Q08_3

Waste generation

Q08_4

Safety of the Workers

Q08_5

Asset photograph available?

Compliance to ESMF
A01

Is the Annexure 6 for Environmental and Social Compliance duly filled in and endorsed as per ESMF guidelines and attached to DPR ?

A02

Whether the due and correct procedure followed for EA (environmental assessment)

A03

CRZ, Forest Clearance, National Park/ Sanctuary, Archaeological Area, Tree cutting, Ground water withdrawal permissions, if applicable, Taken ?

Agriculture – Krishi Bhavan
B01

Original Year of Construction, If Renovated or Repaired

B02

Aesthetic Appearance

B03

Whether relevant rules are followed before identification of location

B04

Whether the same attached to the DPR

B05

Any permissions, NOCs are attached to the DPRs

B06

Whether the land use changed

B07

The earlier land use

B08

Location Plan

B08A

Copy available or not

B08B

approved by authorized civil engineer

B09

Building / Design plan

B09A

Copy available or not

B09B

approved by authorized civil engineer

Natural Resource Depletion
C01

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

C02

Part of Locally available material utilized, in %

C03

Whether any rejection of material recorded

C04

If Yes, Reason

C05

Wood used for

C06

Eco-friendly materials

C07

Source of Water for Construction

C08

Any usage of Ground water

C09

Ventilation Adequate

C10

Natural Light Adequate

C11

Any non-conventional source of energy like Solar, wind, biogas

C12

Energy efficient lighting and fixtures, like LED

C13

Any provision for Rain water harvesting and adequate

C14

Provision for Recycling of Solid waste

C15

Specify the use of following materials

C15_1

Wood

C15_2

Glass

C15_3

Asbestos

C15_4

Agricultural Soil

C15_5

Forest Produce

C16

Provision for treatment of wastewater

C17

Provision for Recycling of wastewater

Waste Management
D01

The left over and waste material disposed by contractor

D02

Provision of Dust bins

D03

Provision for Recycling of Biodegradables

D04

Discharge of wastewater (Write the location)

D05

Permission for Solid waste disposal from competent authority

D06

Permission for Liquid waste disposal from competent authority

Health, Hygiene and Safety
E01

First aid available

E02

Emergency Route and evacuation with signage

E03

Firefighting measures available

E04

Drinking water for staff and visitors

E04A

Toilet facility available

E05

Adequate water in toilets

E06

Separate toilets for Men and Women

Biodiversity
F01

Any Impact on Biodiversity

F02

If yes, measures taken (Write comments)

F03

Any tree cutting

F04

If yes, provide details

F05

If yes, Permission taken from Forest dept

F06

Any compensatory afforestation

F07

If yes, provide details

F08

Any Local species planted

F09

Any land Acquisition

F10

If yes, provide details

F10A

Name of the Land Owner

F10B

Category

F10C

Minutes of the Committee meeting available

F10D

Land Relinquishment available

F10E

Mutation details

F11

Local population Employed Consulted for the project

F12

Local people employed

F13

Project approved from the local body

F14

Any nuisance from construction noise

F15

Operation phase noise from DG, Motor etc

F16

Is the project beneficiary the vulnerable groups

F17

Any complain by local residents

F18

Grievance Redressal done

Anganwadis : Anganwadi building construction / Maintenance / Renovation
G01

Original Year of Construction, If Renovated or Repaired

G02

Aesthetic Appearance

G03

Whether relevant rules are followed before identification of location?

G04

Whether the same attached to the DPR

G05

Any permissions, NOCs are attached to the DPRs

G06

Whether the land use changed ?

G07

The earlier land use

G08

Location Plan

G08A

Copy available or not

G08B

approved by authorized civil engineer

G09

Building / Design plan

G09A

Copy available or not

G09B

approved by authorized civil engineer

G10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

G11

Part of Locally available material utilized, in %

G12

Whether any rejection of material recorded

G12A

Reason

G13

Wood used for

G14

Eco-friendly materials used

G15

Source of Water for Construction

G16

Any usage of Ground water

G17

Ventilation Adequate

G18

Natural Light Adequate

G19

Any non-conventional source of energy like Solar, wind, biogas

G20

Energy efficient lighting and fixtures, like LED

G21

Any provision for Rain water harvesting and adequate

G22

Provision for Recycling of Solid waste

G23

Specify the use of following materials

G23_1

Wood

G23_2

Glass

G23_3

Asbestos

G23_4

Agricultural Soil

G23_5

Forest Produce

G24

Provision for treatment of wastewater available?

G25

Provision for Recycling of wastewater

G26

The left over and waste material disposed by contractor

G27

Provision of Dust bins

G28

Provision for Recycling of Biodegradables

G29

Discharge of wastewater (Write the location)

G30

Permission for Solid waste disposal from competent authority

G31

Permission for Liquid waste disposal from competent authority

G32

First aid available

G33

Emergency Route and evacuation with signage

G34

Firefighting measures available

G35

Drinking water for staff and visitors

G35A

Toilet facility available

G36

Adequate water in toilets

G37

Separate toilets for Men and Women

G38

Any Impact on Biodiversity

G39

If yes, measures taken (Write comments)

G40

Any tree cutting

G41

If yes, provide details

G42

If yes, Permission taken from Forest dept

G43

Any compensatory afforestation

G44

If yes, provide details

G45

Any Local species planted

G46

Any land Acquisition

G47

If yes, provide details

G47_1

Name of the Land Owner

G47_2

Category

G47_3

Minutes of the Committee meeting available

G47_4

Land Relinquishment available

G47_5

Mutation details

G48

Local population Employed Consulted for the project

G49

Local people employed

G50

Project approved from the local body

G51

Any nuisance from construction noise

G52

Operation phase noise from DG, Motor etc

G53

Is the project beneficiary the vulnerable groups

G54

Any complain by local residents

G55

Grievance Redressal done

Animal Husbandry – Veterinary hospital
H01

Type of Institution, Primary health centre, Hospital or Speciality Hospital

H01A

Original Year of Construction, If Renovated or Repaired

H02

Aesthetic Appearance

H03

Whether relevant rules are followed before identification of location

H04

Whether the same attached to the DPR

H05

Any permissions, NOCs are attached to the DPRs

H06

Whether the land use changed

H07

The earlier land use

H08

Location Plan

H08A

Copy available or not

H08B

approved by authorized civil engineer

H09

Building / Design plan

H09A

Copy available or not

H09B

approved by authorized civil engineer

H10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

H11

Part of Locally available material utilized, in %

H12

Whether any rejection of material recorded

H13

If Yes, Reason

H14

Wood used for

H15

Eco-friendly materials

H16

Source of Water for Construction

H17

Any usage of Ground water

H18

Ventilation Adequate

H19

Natural Light Adequate

H20

Any non-conventional source of energy like Solar, wind, biogas

H21

Energy efficient lighting and fixtures, like LED

H22

Any provision for Rain water harvesting and adequate

H23

Provision for Recycling of Solid waste

H24

Specify the use of following materials

H24_1

Wood

H24_2

Glass

H24_3

Asbestos

H24_4

Agricultural Soil

H24_5

Forest Produce

H25

Provision for treatment of wastewater

H26

Provision for Recycling of wastewater

H27

Waste generation

H28

Medical Waste, in Kg per day

H29

Municipal waste, in Kg per day

H30

Provision of Separate Dust bins

H31

Incinerator installed

H32

If yes, Capacity, kg per hour

H33

Authorized vendor for bio-medical waste identified

H34

If Yes, Provide name

H35

Distance from the hospital, in kms

H36

Transportation available?

H37

Any segregation mechanism in place (Biomedical waste from municipal waste)

H38

Color coded bins are available

H39

Discharge of wastewater (Write the location)

H40

Any wastewater treatment facility available

H41

Permission for Liquid waste disposal from competent authority

H42

The incinerator are CPCB compliant

H43

The DG sets are CPCB compliant

H44

Emergency Route and evacuation with signage

H45

Firefighting measures available

H46

Drinking water for staff and Patients

H46A

Toilet facility available

H47

Adequate water in toilets

H48

Separate toilets for Men and Women

H49

Any Impact on Biodiversity

H50

If yes, measures taken (Write comments)

H51

Any tree cutting

H52

If yes, provide details

H53

If yes, Permission taken from Forest dept

H54

Any compensatory afforestation

H55

If yes, provide details

H56

Any Local species planted

H57

Any land Acquisition

H58

If yes, provide details

H58_1

Name of the Land Owner

H58_2

Category

H58_3

Minutes of the Committee meeting available

H58_4

Land Relinquishment available

H58_5

Mutation details

H59

Local population Employed Consulted for the project

H60

Local people employed

H61

Project approved from the local body

H62

Any nuisance from construction noise

H63

Operation phase noise from DG, Motor etc

H64

Is the project beneficiary the vulnerable groups

H65

Any complain by local residents

H66

Grievance Redressal done

Arts, Culture and sports development, Youth welfare:  Playground / Art gallery / Samskarika Nilayam
I01

Original Year of Construction, If Renovated or Repaired

I02

Aesthetic Appearance

I03

Whether relevant rules are followed before identification of location

I04

Whether the same attached to the DPR

I05

Any permissions, NOCs are attached to the DPRs

I06

Whether the land use changed

I07

The earlier land use

I08

Location Plan

I08A

Copy available or not

I08B

approved by authorized civil engineer

I09

Building / Design plan

I09A

Copy available or not

I09B

approved by authorized civil engineer

I10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

I11

Part of Locally available material utilized, in %

I12

Whether any rejection of material recorded

I13

If Yes, Reason

I14

Wood used for

I15

Eco-friendly materials

I16

Source of Water for Construction

I17

Any usage of Ground water

I18

Ventilation Adequate

I19

Natural Light Adequate

I20

Any non-conventional source of energy like Solar, wind, biogas

I21

Energy efficient lighting and fixtures, like LED

I22

Any provision for Rain water harvesting and adequate

I23

Provision for Recycling of Solid waste

I24

Specify the use of following materials

I24_1

Wood

I24_2

Glass

I24_3

Asbestos

I24_4

Agricultural Soil

I24_5

Forest Produce

I25

Provision for treatment of wastewater

I26

Provision for Recycling of wastewater

I27

The left over and waste material disposed by contractor

I28

Provision of Dust bins

I29

Provision for Recycling of Biodegradables

I30

Discharge of wastewater (Write the location)

I31

Permission for Solid waste disposal from competent authority

I32

Permission for Liquid waste disposal from competent authority

I33

First aid available

I34

Emergency Route and evacuation with signage

I35

Firefighting measures available

I36

Drinking water for staff and visitors

I36A

Toilet facility available

I37

Adequate water in toilets

I38

Separate toilets for Men and Women

I39

Any Impact on Biodiversity

I40

If yes, measures taken (Write comments)

I41

Any tree cutting

I42

If yes, provide details

I43

If yes, Permission taken from Forest dept

I44

Any compensatory afforestation

I45

If yes, provide details

I46

Any Local species planted

I47

Any land Acquisition

I48

If yes, provide details

I48_1

Name of the Land Owner

I48_2

Category

I48_3

Minutes of the Committee meeting available

I48_4

Land Relinquishment available

I48_5

Mutation details

I49

Local population Employed Consulted for the project

I50

Local people employed

I51

Project approved from the local body

I52

Any nuisance from construction noise

I53

Operation phase noise from DG, Motor etc

I54

Is the project beneficiary the vulnerable groups

I55

Any complain by local residents

I56

Grievance Redressal done

Computerisation – for panchayat office / Transferred institutions /Schools
J01

Product in working condition

J02

Aesthetic Appearance

J03

Information of the product on make, mfg, certification etc

J04

Brand and Certification

J05

Identification of the authorized dealer and the management of waste after its end use

J06

Power supplies to the computers

J07

The product rated as per BIS norms

J08

The left over and waste material disposed by contractor

J09

Provision of management of E-waste as per provision in E-waste management rules

J10

Safety during Installation

J11

Safety signage/warnings displayed at appropriate places

J12

Hazards are clearly understandable

J13

First aid available

J14

Emergency Route and evacuation with signage

J15

Firefighting measures available

J16

Licenced person engaged in installations

J17

Any incident/accident reported

J18

If yes, provide details

J19

Local population Consulted for the project

J20

Local people employed

J21

Project approved from the local body

J22

Any complain by users

Drinking water: Borewell / Well / Drinking water supply
K01

Original Year of Construction, If Renovated or Repaired/laying of pipeline

K02

Whether relevant rules are followed before identification of location

K03

Whether the same attached to the DPR

K04

Whether CRZ zone

K05

If yes, permission from KSCZMA taken

K06

Any permissions, NOCs are attached to the DPRs

K07

Pipe material

K08

Any water treatment provided

K09

Any system to check water supply

K10

How many hours of water supply

K11

Whether the design has been approved by authorized civil engineer

K12

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

K13

Part of Locally available material utilized, in %

K14

Source of Water supply

K15

Any usage of Ground water

K16

Any non-conventional source of energy like Solar, wind, biogas

K17

Any provision for Rain water harvesting and adequate

K18

Provision of water treatment

K19

Provision for Recycling of wastewater

K20

Discharge of wastewater (Write the location)

K21

Permission for Liquid waste disposal from competent authority

K22

Is there stagnation of water

K23

Any mosquito breeding reported

K24

Are the facility cleaned regularly

K25

Water quality monitoring done

K26

Safeguards provided for the water source

K27

Any Impact on Biodiversity

K28

If yes, measures taken (Write comments)

K29

Any tree cutting

K30

If yes, provide details

K31

If yes, Permission taken from Forest dept

K32

Any compensatory afforestation

K33

If yes, provide details

K34

Any Local species planted

K35

Any land Acquisition

K36

If yes, provide details

K36_1

Name of the Land Owner

K36_2

Category

K36_3

Minutes of the Committee meeting available

K36_4

Land Relinquishment available

K36_5

Mutation details

K37

Local population Employed Consulted for the project

K38

Local people employed

K39

Project approved from the local body

K40

Any nuisance from construction noise

K41

Operation phase noise from DG, Motor etc

K42

Is the project beneficiary the vulnerable groups

K43

Any complain by local residents

K44

Grievance Redressal done

Education -School building / School Ground and Stadium
L01

Original Year of Construction, If Renovated or Repaired

L02

Aesthetic Appearance

L03

Whether relevant rules are followed before identification of location

L04

Whether the same attached to the DPR

L05

Any permissions, NOCs are attached to the DPRs

L06

Whether the land use changed

L07

The earlier land use

L08

Playground Provided

L09

Location Plan

L09A

Copy available or not

L09B

approved by authorized civil engineer

L10

Building / Design plan

L10A

Copy available or not

L10B

approved by authorized civil engineer

L11

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

L12

Part of Locally available material utilized, in %

L13

Whether any rejection of material recorded

L14

If Yes, Reason

L15

Wood used for

L16

Eco-friendly materials

L17

Source of Water for Construction

L18

Any usage of Ground water

L19

Ventilation Adequate

L20

Natural Light Adequate

L21

Any non-conventional source of energy like Solar, wind, biogas

L22

Energy efficient lighting and fixtures, like LED

L23

Any provision for Rain water harvesting and adequate

L24

Provision for Recycling of Solid waste

L25

Specify the use of following materials

L25_1

Wood

L25_2

Glass

L25_3

Asbestos

L25_4

Agricultural Soil

L25_5

Forest Produce

L26

Provision for treatment of wastewater

L27

Provision for Recycling of wastewater

L28

The left over and waste material disposed by contractor

L29

Provision of Dust bins

L30

Provision for Recycling of Biodegradables

L31

Discharge of wastewater (Write the location)

L32

Permission for Solid waste disposal from competent authority

L33

Permission for Liquid waste disposal from competent authority

L34

First aid available

L35

Emergency Route and evacuation with signage

L36

Firefighting measures available

L37

Drinking water for staff and visitors

L37A

Toilet facility available

L38

Adequate water in toilets

L39

Separate toilets for Men and Women

L40

Quiet as per guidelines

L41

Any Impact on Biodiversity

L42

If yes, measures taken (Write comments)

L43

Any tree cutting

L44

If yes, provide details

L45

If yes, Permission taken from Forest dept

L46

Any compensatory afforestation

L47

If yes, provide details

L48

Any Local species planted

L49

Any land Acquisition

L50

If yes, provide details

L50_1

Name of the Land Owner

L50_2

Category

L50_3

Minutes of the Committee meeting available

L50_4

Land Relinquishment available

L50_5

Mutation details

L51

Local population Employed Consulted for the project

L52

Local people employed

L53

Project approved from the local body

L54

Any nuisance from construction noise

L55

Operation phase noise from DG, Motor etc

L56

Is the project beneficiary the vulnerable groups

L57

Any complain by local residents

L58

Grievance Redressal done

Electric line, Transformer
M01

Quality of Construction

M02

Whether relevant rules are followed before identification of project

M03

Whether the same attached to the DPR

M04

Any permissions, NOCs are attached to the DPRs

M05

Is it Greenfield project

M06

If Yes, the earlier land use

M07

Any electric safety signage provision

M08

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

M09

Part of Locally available material utilized, in %

M10

Eco-friendly materials

M11

Source of Water for Construction of foundation (Pond/River/Municipal/Ground water)

M12

Any usage of Ground water

M13

Energy efficient lighting and fixtures, like LED

M14

Provision for Storm water

M15

The left over and waste material disposed by contractor

M16

Any Recycling of construction debris

M17

Electrical safety signage available

M18

Emergency Route and evacuation with signage

M19

Any littering along the pathway of the electric lines

M20

Electric supply improved?

M21

Hazards identification and provisions made

M22

Is there any point of contact on first aid

M23

Any Impact on Biodiversity

M24

Any nesting ground near the alignment

M25

If yes, provide details

M26

The alignment Passes through any National park, wild life zones or any other eco sensitive areas like western ghats, CRZ etc

M27

If yes, measures taken to mitigate the impact (Write comments)

M28

Any tree cutting

M29

If yes, provide details

M30

If yes, Permission taken from Forest dept

M31

Any compensatory afforestion

M32

If yes, provide details

M33

Any Local species planted, provide details

M34

Any other specific action on the issue to mitigate the problem during design or construction

M35

Any land Acquisition

M36

If yes, provide details

M36_1

Name of the Land Owner

M36_2

Category

M36_3

Minutes of the Committee meeting available

M36_4

Land Relinquishment available

M36_5

Mutation details

M37

Local population Employed Consulted for the project

M38

Local people employed

M39

Project approved from the local body

M40

Any nuisance from construction noise

M41

Operation phase noise from DG, Motor etc

M42

Is the project beneficiary the vulnerable groups

M43

Any complain by local residents

M44

Grievance Redressal done

Energy generation/ Energy protection – Solar street lights
N01

Quality of Construction

N02

Whether relevant rules are followed before identification of project

N03

Whether the same attached to the DPR

N04

Any permissions, NOCs are attached to the DPRs

N05

Is it Greenfield project

N06

If Yes, the earlier land use

N07

Any electric safety signage provision

N08

Whether the Locally available material utilized, named Moorum, Brick, Sand, stone for foundation etc.

N09

Part of Locally available material utilized, in %

N10

Eco-friendly materials

N11

Source of Water for Construction of foundation (Pond/River/Municipal/Ground water)

N12

Any usage of Ground water

N13

Energy efficient lighting and fixtures, like LED

N14

Provision for Storm water

N15

The left over and waste material disposed by contractor

N16

Any Recycling of construction debris

N17

Electrical safety signage available

N18

Emergency Route and evacuation with signage

N19

Any littering along the pathway of the electric lines

N20

Electric supply improved?

N21

Hazards identification and provisions made

N22

Is there any point of contact on first aid

N23

Any Impact on Biodiversity

N24

Any nesting ground near the alignment

N25

If yes, provide details

N26

The alignment Passes through any National park, wild life zones or any other eco sensitive areas like western ghats, CRZ etc

N27

If yes, measures taken to mitigate the impact (Write comments)

N28

Any tree cutting

N29

If yes, provide details

N30

If yes, Permission taken from Forest dept

N31

Any compensatory afforestation

N32

If yes, provide details

N33

Any Local species planted

N34

Any other specific action on the issue to mitigate the problem during design or construction

N35

Any land Acquisition

N36

If yes, provide details

N36_1

Name of the Land Owner

N36_2

Category

N36_3

Minutes of the Committee meeting available

N36_4

Land Relinquishment available

N36_5

Mutation details

N37

Local population Employed Consulted for the project

N38

Local people employed

N39

Project approved from the local body

N40

Any nuisance from construction noise

N41

Operation phase noise from DG, Motor etc

N42

Is the project beneficiary the vulnerable groups

N43

Any complain by local residents

N44

Grievance Redressal done

Street light, Office electrification: Street lights, High mast lighting, Office electrification
O01

Asset in working condition

O02

Aesthetic Appearance

O03

Information of the product on make, mfg, certification etc

O04

Brand and Certification

O05

Identification of the authorized dealer and the management of waste after its end use

O06

Laying of electrical lines

O07

The product rated as per BIS norms

O08

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

O09

Part of Locally available material utilized, in %

O10

Whether any rejection of material recorded

O11

If Yes, Reason

O12

Wood used for

O13

Eco-friendly materials

O14

Source of Water for Construction

O15

Any usage of Ground water

O16

Ventilation Adequate

O17

Natural Light Adequate

O18

Any non-conventional source of energy like Solar, wind, biogas

O19

Energy efficient lighting and fixtures, like LED

O20

Any provision for Rain water harvesting and adequate

O21

Provision for Recycling of Solid waste

O22

Specify the use of following materials

O22_1

Wood

O22_2

Glass

O22_3

Asbestos

O22_4

Agricultural Soil

O22_5

Forest Produce

O23

Provision for treatment of wastewater

O24

Provision for Recycling of wastewater

O25

The left over and waste material disposed by contractor

O26

Provision of management of E-waste as per provision in E-waste management rules

O27

Safety during Installation

O28

Safety signage/warnings displayed at appropriate places

O29

First aid available

O30

Emergency Route and evacuation with signage

O31

Firefighting measures available

O32

Licenced person engaged in installations

O33

Any incident/accident reported

O34

If yes, provide details

O35

Any Impact on Biodiversity

O36

If yes, measures taken (Write comments)

O37

Any tree cutting

O38

If yes, provide details

O39

If yes, Permission taken from Forest dept

O40

Any compensatory afforestation

O41

If yes, provide details

O42

Any Local species planted

O43

Any land Acquisition

O44

If yes, provide details

O44_1

Name of the Land Owner

O44_2

Category

O44_3

Minutes of the Committee meeting available

O44_4

Land Relinquishment available

O44_5

Mutation details

O45

Local population Employed Consulted for the project

O46

Local people employed

O47

Project approved from the local body

O48

Any nuisance from construction noise

O49

Operation phase noise from DG, Motor etc

O50

Is the project beneficiary the vulnerable groups

O51

Any complain by local residents

O52

Grievance Redressal done

Health – Hospitals (PHC, CHC)
P01A

Type of Institution, Primary health centre, Hospital or Speciality Hospital

P01

Original Year of Construction, If Renovated or Repaired

P02

Aesthetic Appearance

P03

Whether relevant rules are followed before identification of location

P04

Whether the same attached to the DPR

P05

Any permissions, NOCs are attached to the DPRs

P06

Whether the land use changed

P07

The earlier land use

P08

Location Plan

P08A

Copy available or not

P08B

approved by authorized civil engineer

P09

Building / Design plan

P09A

Copy available or not

P09B

approved by authorized civil engineer

P10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

P11

Part of Locally available material utilized, in %

P12

Whether any rejection of material recorded

P13

If Yes, Reason

P14

Wood used for

P15

Eco-friendly materials

P16

Source of Water for Construction

P17

Any usage of Ground water

P18

Ventilation Adequate

P19

Natural Light Adequate

P20

Any non-conventional source of energy like Solar, wind, biogas

P21

Energy efficient lighting and fixtures, like LED

P22

Any provision for Rain water harvesting and adequate

P23

Provision for Recycling of Solid waste

P24

Specify the use of following materials

P24_1

Wood

P24_2

Glass

P24_3

Asbestos

P24_4

Agricultural Soil

P24_5

Forest Produce

P25

Provision for treatment of wastewater

P26

Provision for Recycling of wastewater

P27

Waste generation

P28

Medical Waste, in Kg per day

P29

Municipal waste, in Kg per day

P30

Provision of Separate Dust bins

P31

Incinerator installed

P32

If yes, Capacity, kg per hour

P33

Authorized vendor for bio-medical waste identified

P34

If Yes, Provide name

P35

Distance from the hospital, in kms

P36

Transportation available?

P37

Any segregation mechanism in place (Biomedical waste from municipal waste)

P38

Color coded bins are available

P39

Discharge of wastewater (Write the location)

P40

Any wastewater treatment facility available

P41

Permission for Liquid waste disposal from competent authority

P42

The incinerator are CPCB compliant

P43

The DG sets are CPCB compliant

P44

Emergency Route and evacuation with signage

P45

Firefighting measures available

P46

Drinking water for staff and Patients

P46A

Toilet facility available

P47

Adequate water in toilets

P48

Separate toilets for Men and Women

P49

Any Impact on Biodiversity

P50

If yes, measures taken (Write comments)

P51

Any tree cutting

P52

If yes, provide details

P53

If yes, Permission taken from Forest dept

P54

Any compensatory afforestation

P55

If yes, provide details

P56

Any Local species planted

P57

Any land Acquisition

P58

If yes, provide details

P58_1

Name of the Land Owner

P58_2

Category

P58_3

Minutes of the Committee meeting available

P58_4

Land Relinquishment available

P58_5

Mutation details

P59

Local population Employed Consulted for the project

P60

Local people employed

P61

Project approved from the local body

P62

Any nuisance from construction noise

P63

Operation phase noise from DG, Motor etc

P64

Is the project beneficiary the vulnerable groups

P65

Any complain by local residents

P66

Grievance Redressal done

Housing, House Electrification
R01

Asset in working condition

R02

Aesthetic Appearance

R03

Information of the product on make, mfg, certification etc

R04

Brand and Certification

R05

Identification of the authorized dealer and the management of waste after its end use

R06

Laying of electrical lines

R07

The product rated as per BIS norms

R08

Location Plan

R08A

Copy available or not

R08B

approved by authorized civil engineer

R09

Building / Design plan

R09A

Copy available or not

R09B

approved by authorized civil engineer

R10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

R11

Part of Locally available material utilized, in %

R12

Whether any rejection of material recorded

R13

If Yes, Reason

R14

Wood used for

R15

Eco-friendly materials

R16

Source of Water for Construction

R17

Any usage of Ground water

R18

Ventilation Adequate

R19

Natural Light Adequate

R20

Any non-conventional source of energy like Solar, wind, biogas

R21

Energy efficient lighting and fixtures, like LED

R22

Any provision for Rain water harvesting and adequate

R23

Provision for Recycling of Solid waste

R24

Specify the use of following materials

R24_1

Wood

R24_2

Glass

R24_3

Asbestos

R24_4

Agricultural Soil

R24_5

Forest Produce

R25

Provision for treatment of wastewater

R26

Provision for Recycling of wastewater

R27

The left over and waste material disposed by contractor

R28

Provision of Dust bins

R29

Provision for Recycling of Biodegradables

R30

Discharge of wastewater (Write the location)

R31

Permission for Solid waste disposal from competent authority

R32

Permission for Liquid waste disposal from competent authority

R33

Safety during Installation

R34

Safety signage/warnings displayed at appropriate places

R35

First aid available

R36

Emergency Route and evacuation with signage

R37

Firefighting measures available

R38

Licenced person engaged in installations

R39

Any incident/accident reported

R40

If yes, provide details

R41

Any Impact on Biodiversity

R42

If yes, measures taken (Write comments)

R43

Any tree cutting

R44

If yes, provide details

R45

If yes, Permission taken from Forest dept

R46

Any compensatory afforestation

R47

If yes, provide details

R48

Any Local species planted

R49

Any land Acquisition

R50

If yes, provide details

R50_1

Name of the Land Owner

R50_2

Category

R50_3

Minutes of the Committee meeting available

R50_4

Land Relinquishment available

R50_5

Mutation details

R51

Local population Employed Consulted for the project

R52

Local people employed

R53

Project approved from the local body

R54

Any nuisance from construction noise

R55

Operation phase noise from DG, Motor etc

R56

Is the project beneficiary the vulnerable groups

R57

Any complain by local residents

R58

Grievance Redressal done

Irrigation – Minor or micro irrigation projects
S01

Analysis of all alternatives carried out

S02

Whether relevant rules are followed before identification of location

S03

Seasonal or Perennial Project

S04

Purpose; Drinking, Agriculture, Irrigation,

S05

Source of water

S06

Any change in layout and design after due consideration of Environment and social issues

S07

Whether water quality as per agriculture use category of water

S08

Whether natural drainage followed for the project

S09

Whether the motor used for pumping is more than 5 HP

S10

Whether the same attached to the DPR

S11

Any permissions, NOCs are attached to the DPRs

S12

Whether the land use changed

S13

If Yes, the earlier land use

S14

Side protection provided

S15

Management of excavated material

S16

Whether the top soil stored and reused

S17

Whether the Locally available material utilized, named Brick, Sand, stone etc.

S18

Any land use change

S19

Any paddy land involved

S20

Soil erosion protection measures taken

S21

Power source available

S22

The left over and waste material disposed by contractor at a safer place

S23

Water quality test prior to start of the project

S24

Was it done according to IS 10500

S25

Any periodic check of water quality

S26

Any water logging result in mosquito breeding

S27

Any nuisance to local public

S28

Any Impact on Biodiversity

S29

If yes, measures taken (Write comments)

S30

Any tree cutting

S31

If yes, provide details

S32

If yes, Permission taken from Forest dept

S33

Any compensatory afforestation

S34

If yes, provide details

S35

Any Local species planted

S36

Any land Acquisition

S37

If yes, provide details

S37_1

Name of the Land Owner

S37_2

Category

S37_3

Minutes of the Committee meeting available

S37_4

Land Relinquishment available

S37_5

Mutation details

S38

Local population Employed Consulted for the project

S39

Local people employed

S40

Project approved from the local body

S41

Any nuisance from construction noise

S42

Operation phase noise from DG, Motor etc

S43

Is the project beneficiary the vulnerable groups

S44

Any complain by local residents

S45

Grievance Redressal done

Other construction works
T01

Original Year of Construction, If Renovated or Repaired

T02

Aesthetic Appearance

T03

Whether relevant rules are followed before identification of location

T04

Whether the same attached to the DPR

T05

Any permissions, NOCs are attached to the DPRs

T06

Whether the land use changed

T07

The earlier land use

T08

Location Plan

T08A

Copy available or not

T08B

approved by authorized civil engineer

T09

Building / Design plan

T09A

Copy available or not

T09B

approved by authorized civil engineer

T10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

T11

Part of Locally available material utilized, in %

T12

Whether any rejection of material recorded

T13

If Yes, Reason

T14

Wood used for

T15

Eco-friendly materials

T16

Source of Water for Construction

T17

Any usage of Ground water

T18

Ventilation Adequate

T19

Natural Light Adequate

T20

Any non-conventional source of energy like Solar, wind, biogas

T21

Energy efficient lighting and fixtures, like LED

T22

Any provision for Rain water harvesting and adequate

T23

Provision for Recycling of Solid waste

T24

Specify the use of following materials

T24_1

Wood

T24_2

Glass

T24_3

Asbestos

T24_4

Agricultural Soil

T24_5

Forest Produce

T25

Provision for treatment of wastewater

T26

Provision for Recycling of wastewater

T27

The left over and waste material disposed by contractor

T28

Provision of Dust bins

T29

Provision for Recycling of Biodegradables

T30

Discharge of wastewater (Write the location)

T31

Permission for Solid waste disposal from competent authority

T32

Permission for Liquid waste disposal from competent authority

T33

First aid available

T34

Emergency Route and evacuation with signage

T35

Firefighting measures available

T36

Drinking water for staff and visitors

T36A

Toilet facility available

T37

Adequate water in toilets

T38

Separate toilets for Men and Women

T39

Any Impact on Biodiversity

T40

If yes, measures taken (Write comments)

T41

Any tree cutting

T42

If yes, provide details

T43

If yes, Permission taken from Forest dept

T44

Any compensatory afforestation

T45

If yes, provide details

T46

Any Local species planted

T47

Any land Acquisition

T48

If yes, provide details

T48_1

Name of the Land Owner

T48_2

Category

T48_3

Minutes of the Committee meeting available

T48_4

Land Relinquishment available

T48_5

Mutation details

T49

Local population Employed Consulted for the project

T50

Local people employed

T51

Project approved from the local body

T52

Any nuisance from construction noise

T53

Operation phase noise from DG, Motor etc

T54

Is the project beneficiary the vulnerable groups

T55

Any complain by local residents

T56

Grievance Redressal done

Soil-water conservation, Environment, afforestation
U01

Material of Construction

U02

Whether the bund constructed around the paddy field in good condition and crack free

U03

Any stagnation reported inconvenience to local people

U04

Leads to mosquito breeding

U05

Whether the confined water used by local people causing pollution and nuisance

U06

If Yes, Provide details

U07

Any growth of Aquatic weeds

U08

Is there a positive impact on biodiversity

U09

Is there a negative impact on biodiversity

U10

If Yes, Provide details

U11

Public Consultation done

U12

Variety of Saplings (mention type)

U13

Is it local, hybrid, exotic

U14

When the sapling was planted (Record the date)

U15

% of sapling survived

U16

Purpose of plantation

U17

Density

U18

Any impact on biodiversity

U19

If Yes, provide details

U20

Whether the variety economically viable

U21

Any protection work done

U22

Is it irrigated

U23

Any water logging

U24

Whether Fertilizers are used

U25

Organic fertilizers are used

Public Buildings which are not included in productive and service
V01

Original Year of Construction, If Renovated or Repaired

V02

Aesthetic Appearance

V03

Whether relevant rules are followed before identification of location

V04

Whether the same attached to the DPR

V05

Any permissions, NOCs are attached to the DPRs

V06

Whether the land use changed

V07

The earlier land use

V08

Location Plan

V08A

Copy available or not

V08B

approved by authorized civil engineer

V09

Building / Design plan

V09A

Copy available or not

V09B

approved by authorized civil engineer

V10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

V11

Part of Locally available material utilized, in %

V12

Whether any rejection of material recorded

V13

If Yes, Reason

V14

Wood used for

V15

Eco-friendly materials

V16

Source of Water for Construction

V17

Any usage of Ground water

V18

Ventilation Adequate

V19

Natural Light Adequate

V20

Any non-conventional source of energy like Solar, wind, biogas

V21

Energy efficient lighting and fixtures, like LED

V22

Any provision for Rain water harvesting and adequate

V23

Provision for Recycling of Solid waste

V24

Specify the use of following materials

V24_1

Wood

V24_2

Glass

V24_3

Asbestos

V24_4

Agricultural Soil

V24_5

Forest Produce

V25

Provision for treatment of wastewater

V26

Provision for Recycling of wastewater

V27

The left over and waste material disposed by contractor

V28

Provision of Dust bins

V29

Provision for Recycling of Biodegradables

V30

Discharge of wastewater (Write the location)

V31

Permission for Solid waste disposal from competent authority

V32

Permission for Liquid waste disposal from competent authority

V33

First aid available

V34

Emergency Route and evacuation with signage

V35

Firefighting measures available

V36

Drinking water for staff and visitors

V36A

Toilet facility available

V37

Adequate water in toilets

V38

Separate toilets for Men and Women

V39

Any Impact on Biodiversity

V40

If yes, measures taken (Write comments)

V41

Any tree cutting

V42

If yes, provide details

V43

If yes, Permission taken from Forest dept

V44

Any compensatory afforestation

V45

If yes, provide details

V46

Any Local species planted

V47

Any land Acquisition

V48

If yes, provide details

V48_1

Name of the Land Owner

V48_2

Category

V48_3

Minutes of the Committee meeting available

V48_4

Land Relinquishment available

V48_5

Mutation details

V49

Local population Employed Consulted for the project

V50

Local people employed

V51

Project approved from the local body

V52

Any nuisance from construction noise

V53

Operation phase noise from DG, Motor etc

V54

Is the project beneficiary the vulnerable groups

V55

Any complain by local residents

V56

Grievance Redressal done

Reading Rooms, Libraries and Grama sabha /ward sabha centres
W01

Original Year of Construction, If Renovated or Repaired

W02

Aesthetic Appearance

W03

Whether relevant rules are followed before identification of location

W04

Whether the same attached to the DPR

W05

Any permissions, NOCs are attached to the DPRs

W06

Whether the land use changed

W07

The earlier land use

W08

Location Plan

W08A

Copy available or not

W08B

approved by authorized civil engineer

W09

Building / Design plan

W09A

Copy available or not

W09B

approved by authorized civil engineer

W10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

W11

Part of Locally available material utilized, in %

W12

Whether any rejection of material recorded

W13

If Yes, Reason

W14

Wood used for

W15

Eco-friendly materials

W16

Source of Water for Construction

W17

Any usage of Ground water

W18

Ventilation Adequate

W19

Natural Light Adequate

W20

Any non-conventional source of energy like Solar, wind, biogas

W21

Energy efficient lighting and fixtures, like LED

W22

Any provision for Rain water harvesting and adequate

W23

Provision for Recycling of Solid waste

W24

Specify the use of following materials

W24_1

Wood

W24_2

Glass

W24_3

Asbestos

W24_4

Agricultural Soil

W24_5

Forest Produce

W25

Provision for treatment of wastewater

W26

Provision for Recycling of wastewater

W27

The left over and waste material disposed by contractor

W28

Provision of Dust bins

W29

Provision for Recycling of Biodegradables

W30

Discharge of wastewater (Write the location)

W31

Permission for Solid waste disposal from competent authority

W32

Permission for Liquid waste disposal from competent authority

W33

First aid available

W34

Emergency Route and evacuation with signage

W35

Firefighting measures available

W36

Drinking water for staff and visitors

W36A

Toilet facility available

W37

Adequate water in toilets

W38

Separate toilets for Men and Women

W39

Any Impact on Biodiversity

W40

If yes, measures taken (Write comments)

W41

Any tree cutting

W42

If yes, provide details

W43

If yes, Permission taken from Forest dept

W44

Any compensatory afforestation

W45

If yes, provide details

W46

Any Local species planted

W47

Any land Acquisition

W48

If yes, provide details

W48_1

Name of the Land Owner

W48_2

Category

W48_3

Minutes of the Committee meeting available

W48_4

Land Relinquishment available

W48_5

Mutation details

W49

Local population Employed Consulted for the project

W50

Local people employed

W51

Project approved from the local body

W52

Any nuisance from construction noise

W53

Operation phase noise from DG, Motor etc

W54

Is the project beneficiary the vulnerable groups

W55

Any complain by local residents

W56

Grievance Redressal done

Sanitation, Waste processing: Drainage / Toilets/ bathing places / solid waste management / crematoriums
X01

Original Year of Construction of Toilets/sanitary facility, If Renovated or Repaired

X02

Quality of Construction

X03

Whether relevant rules are followed before identification of project

X04

Whether the same attached to the DPR

X05

Any permissions, NOCs are attached to the DPRs

X06

Is it Greenfield project

X07

If Yes, the earlier land use

X08

Provision of Electricity

X09

Provision of water supply

X10

Location Plan

X10A

Copy available or not

X10B

approved by authorized civil engineer

X11

Building / Design plan

X11A

Copy available or not

X11B

approved by authorized civil engineer

X12

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

X13

Part of Locally available material utilized, in %

X14

Any usage of Ground water

X15

Any non-conventional source of energy like Solar, wind, biogas for Street lighting

X16

Energy efficient lighting and fixtures, like LED

X17

Provision for Recycling of Solid waste

X18

Provision for Storm water

X19

Method of collection of solid waste

X20

Frequency of collection

X21

Vehicle of collection

X22

The left over and waste material disposed by contractor

X23

Any provision for on-site treatment

X24

If yes, Provide details

X25

If No, Point of disposal with distance

X26

Any discharge in local water body

X27

Any discharge in open area

X28

Is the area clean or in mess

X29

Disposal of Solid waste

X30

Method of Disposal/Reuse

X31

Any compost plant

X32

Does the site look clean

X33

Any bad odour from the facility

X34

Cleaning/Sweeping ensured?

X35

Frequency

X36

Any littering nearby

X37

Waste bins provided nearby?

X38

Any mosquito breeding reported

X39

Water borne/Vector borne disease increased?

X40

Protection of Leaching of liquid waste

X41

Any provision to management of Birds, Rodents, Stray animals in and around the dumping facility/project sites

X42

If Yes, Provide details

X43

Is there any point of contact on first aid

X44

Any Impact on Biodiversity

X45

If yes, measures taken (Write comments)

X46

Any tree cutting

X47

If yes, provide details

X48

If yes, Permission taken from Forest dept

X49

Any compensatory afforestation

X50

If yes, provide details

X51

Any Local species planted

X52

Any other specific action on the issue to mitigate the problem during design or construction

X53

Any land Acquisition

X54

If yes, provide details

X54_1

Name of the Land Owner

X54_2

Category

X54_3

Minutes of the Committee meeting available

X54_4

Land Relinquishment available

X54_5

Mutation details

X55

Local population Employed Consulted for the project

X56

Local people employed

X57

Project approved from the local body

X58

Any nuisance from construction noise

X59

Operation phase noise from DG, Motor etc

X60

Is the project beneficiary the vulnerable groups

X61

Any complain by local residents

X62

Grievance Redressal done

Social welfare, social security
Y01

Original Year of Construction, If Renovated or Repaired

Y02

Aesthetic Appearance

Y03

Whether relevant rules are followed before identification of location

Y04

Whether the same attached to the DPR

Y05

Any permissions, NOCs are attached to the DPRs

Y06

Whether the land use changed

Y07

The earlier land use

Y08

Location Plan

Y08A

Copy available or not

Y08B

approved by authorized civil engineer

Y09

Building / Design plan

Y09A

Copy available or not

Y09B

approved by authorized civil engineer

Y10

Whether the Locally available material utilized, named Bamboo, Brick, Sand, stone etc.

Y11

Part of Locally available material utilized, in %

Y12

Whether any rejection of material recorded

Y13

If Yes, Reason

Y14

Wood used for

Y15

Eco-friendly materials

Y16

Source of Water for Construction

Y17

Any usage of Ground water

Y18

Ventilation Adequate

Y19

Natural Light Adequate

Y20

Any non-conventional source of energy like Solar, wind, biogas

Y21

Energy efficient lighting and fixtures, like LED

Y22

Any provision for Rain water harvesting and adequate

Y23

Provision for Recycling of Solid waste

Y24

Specify the use of following materials

Y24_1

Wood

Y24_2

Glass

Y24_3

Asbestos

Y24_4

Agricultural Soil

Y24_5

Forest Produce

Y25

Provision for treatment of wastewater

Y26

Provision for Recycling of wastewater

Y27

The left over and waste material disposed by contractor

Y28

Provision of Dust bins

Y29

Provision for Recycling of Biodegradables

Y30

Discharge of wastewater (Write the location)

Y31

Permission for Solid waste disposal from competent authority

Y32

Permission for Liquid waste disposal from competent authority

Y33

First aid available

Y34

Emergency Route and evacuation with signage

Y35

Firefighting measures available

Y36

Drinking water for staff and visitors

Y36A

Toilet facility available

Y37

Adequate water in toilets

Y38

Separate toilets for Men and Women

Y39

Any Impact on Biodiversity

Y40

If yes, measures taken (Write comments)

Y41

Any tree cutting

Y42

If yes, provide details

Y43

If yes, Permission taken from Forest dept

Y44

Any compensatory afforestation

Y45

If yes, provide details

Y46

Any Local species planted

Y47

Any land Acquisition

Y48

If yes, provide details

Y48_1

Name of the Land Owner

Y48_2

Category

Y48_3

Minutes of the Committee meeting available

Y48_4

Land Relinquishment available

Y48_5

Mutation details

Y49

Local population Employed Consulted for the project

Y50

Local people employed

Y51

Project approved from the local body

Y52

Any nuisance from construction noise

Y53

Operation phase noise from DG, Motor etc

Y54

Is the project beneficiary the vulnerable groups

Y55

Any complain by local residents

Y56

Grievance Redressal done

Transport (Road /culvert/small bridges/foot paths/side walls/path ways-construction, renovation, maintenance)
Z01

Original Year of Construction of Road/Bridge/Culvert, If Renovated or Repaired

Z02

Current quality of the asset

Z03

Whether relevant rules are followed before identification of project ?

Z04

Whether the same attached to the DPR

Z05

Any permissions, NOCs are attached to the DPRs ?

Z06

Is it Greenfield project

Z07

If Yes, the earlier land use

Z08

Location Plan

Z08A

Copy available or not

Z08B

approved by authorized civil engineer

Z09

Building / Design plan

Z09A

Copy available or not

Z09B

approved by authorized civil engineer

Z10

Whether the Locally available material utilized, named Moorum, Brick, Sand, stone etc.

Z11

Part of Locally available material utilized, in %

Z12

Whether any rejection of material recorded

Z13

If Yes, Reason

Z14

Wood used for

Z15

Eco-friendly materials

Z16

Source of Water for Construction (Pond/River/Municipal/Ground water)

Z17

Any usage of Ground water during construction

Z18

Any non-conventional source of energy like Solar, wind, biogas for Street lighting during construction

Z19

Energy efficient lighting and fixtures, like LED – Street lights

Z20

Any provision for Rain water harvesting pits

Z21

Provision for Recycling of Solid waste during construction

Z22

Specify the use of following materials during construction

Z22_1

Wood

Z22_2

Glass

Z22_3

Asbestos

Z22_4

Agricultural Soil

Z22_5

Forest Produce

Z23

Provision for Storm water conservation or flow

Z24

The left over and waste material disposed by contractor

Z25

Any Recycling of construction debris

Z26

If New BC , fate of scarified material disposed

Z27

Road safety signage available

Z28

Emergency Route and evacuation with signage during the construction

Z29

Sweeping ensured?

Z30

Any littering along the pathway

Z31

Waste bins provided in the municipal areas?

Z32

Average speed increased?

Z33

Accidents increased?

Z34

Is there any point of contact on first aid

Z35

Any Impact on Biodiversity

Z36

Any nesting ground near the alignment

Z37

If yes, provide details

Z38

The alignment Passes through any National park, wild life zones or any other eco sensitive areas like western ghats, CRZ etc

Z39

If yes, measures taken to mitigate the impact (Write comments)

Z40

Any tree cutting

Z41

If yes, provide details

Z42

If yes, Permission taken from Forest dept

Z43

Any compensatory afforestion

Z44

If yes, provide details

Z45

Any Local species planted, provide details

Z46

Any other specific action on the issue to mitigate the problem during design or construction

Z47

Any land Acquisition

Z48

If yes, provide details

Z48_1

Name of the Land Owner

Z48_2

Category

Z48_3

Minutes of the Committee meeting available

Z48_4

Land Relinquishment available

Z48_5

Mutation details

Z49

Local population Employed Consulted for the project

Z50

Local people employed

Z51

Project approved from the local body

Z52

Any nuisance from construction noise

Z53

Operation phase noise from DG, Motor etc

Z54

Is the project beneficiary the vulnerable groups

Z55

Any complain by local residents

Z56

Grievance Redressal done