Title Page
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Conducted on
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Prepared by
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Location
General Project Questions
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Give brief, complete description of your proposal, including the proposed uses and the size of the project and site.
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Do you have specific address(s) or locations for the project?
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Please provide the location/address.
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Do you have a proposed timing or schedule for your project?
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Please provide your timing or schedule.
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Do you have any plans for future additions, expansion, or further activity related to or connected with this proposal?
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Please describe these future plans and provide dates or milestones if known.
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What is the current use of the site and adjacent properties?
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Will the proposal affect current land uses on nearby or adjacent properties?
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Please describe what these impacts are and what the current plans are to mitigate these impacts.
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Will permits be required for your project?
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Please list the permits, the permitting agency and whether the permit has been request, issued, or no action yet.
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Has any environmental or social impact information been prepared, or will be prepared, directly related to this proposal?
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Please describe and or attach any of this information.
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Attach any environmental or social information, reports, or studies related to this project.
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Are there any environmental health hazards, including exposure to toxic chemicals, risk of fire and explosion, spill, or hazardous waste that could occur as a result of this proposal?
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Please describe these risks and the plans to mitigate them.
ESMS Assessment
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Does the Fund have a mechanism in place to identify and categorize risk?
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Attach a scanned copy of this mechanism/policy/procedure.
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Does the Fund have a process to oversee ESH issues?
Worker Grievance Mechanism Analysis
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Are there two separate methods of submitting the grievance? ADD if yes - describe the two methods
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Is one method anonymous?
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Are grievances monitored? ADD IF YES - how?
