ANNEX A

RAPID SUBPROJECT SUSTAINABILITY ASSESSMENT (RSSA)

FOR WATER SUPPLY SYSTEM
Date of Assessment (mm/dd/yy):__________________________________________________________
(1) Program: SALINTUBIG BuB-PWS ADM-WS AM-WS PAMANA-Water
Funding Year: ______________________________
Project ID: ______________________________

(2) Title of Project: ________________________________________________________________________

Project Location (Sitio/Purok, Brgy, Municipality,City, Province): _________________________
______________________________________________________________________________________
Mode of Implementation: By Contract By Administration
Level of Service: Level I Level II Level III Level II & III
Nature of Project: New Construction Upgrading Expansion Rehabilitation

(3) Source of Funds: (Fixed Data from SubayBAYAN – All forms Annex A – D/ no need encoding)
National Subsidy PHP (Data from Subay BAYAN
LGU Counterpart PHP (Data from Subay BAYAN
Other Source of Fund (Please Specify)___________________ PHP (Data from Subay BAYAN
Total Project Cost PHP (Data from Subay BAYAN

(4) Date Project Completed (mm/dd/yy): _______________________________________________

(5) Is the Project booked-up as LGU asset? (Refer to LGU Accountant)

Yes (Attach proof of booking-JEV and attachment) No

(6) Is the Project Insured?

Yes (Attach proof of insurance and attachment) No

If yes, they can
(7) Is it still FUNCTIONAL? Yes select 1 or both No
Additional table
(7.a) If YES: include in the
System in place are in good working condition Suitable for Drinking DCF for Water
Improvements made (If any) Estimated Cost Responsible Office
1.
2.
3.
(7.b.1) If NO, state the reasons:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(7.b.2) No. of Months NON-FUNCTIONAL: ________________

(8) CATEGORY OF NON-FUNCTIONALITY:

DISASTER SOURCE DESIGN CONSTRUCTION MAINTENANCE INSTITUTIONAL

(9) Is it still OPERATIONAL? Yes No

(9.a) If YES:
System is being managed Sufficient Supply of Water Others (specify)
_______________________
Who manages the facility? __________
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 ANNEX A
BWSA LGU Managed Water Districts Others (specify) _________
If managed, does it have the following attributes? (Tick all items applicable)
List of Officers Registered by an accredited entity (DA, SEC...) By Laws
Tariff Collection - How much? PHP ____________ per container or per week or per month
Is the facility regularly maintained? Yes No
How much is the annual maintenance budget? PHP______________________________________

(9.b.1) If NO, state the reasons:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(9.b.2) No. of Months NON-OPERATIONAL: ________________

Is the community aware of the project facility? Yes No

Is the facility being used according to its intended purpose? Yes No
If No, why?
Include No. 10______________________________________________________________________________
_________________________________________________________________________________________
in the DCF
_________________________________________________________________________________________

(10) Needed interventions to make it functional/operational and its estimated cost.

(Prioritize the need according to urgency)
Improvements made Estimated Cost Responsible
Needed Interventions Estimated Cost
(If any) Office
(10.a) (10.b)
(10.c)
1.
2.
3.

Photos: (Please attach)

Changes from
DILG PO to Mayor
Prepared by: Conforme:
(All forms)
___________________________ _____________________________
Municipal Engineer Mayor

NOTED:

_____________________________
C/MLGOO

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