SGLGB Form 4 (Checklist)

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the City / Municipal Local Government Officer

Remarks (pls. indicate if

Indicator Data Requirements
no data)
1. Level of Compliance with  BFDP Compliance:
the Barangay Full CY 2018 4Q ________
Disclosure Policy (BFDP)
 Presence of the BFDP Board

2. Functionality of the  BPOC Monitoring Form 2:

Barangay Peace and Order Functionality of the BPOC ___________
Committee (BPOC)
pursuant to DILG MC
2008-101
3. Functionality of the  AO/EO/Ordinance or similar issuance
Barangay Anti-Drug Abuse organizing the BADAC:
Council (BADAC) pursuant Yes _____ No______
to DILG-DDB JMC No.
2018-101  IEC on illegal drug demand reduction:
Yes _____ No______

 Date of last meeting: ______________

 Committee on Operations:
Yes _____ No______

 Committee on Advocacy:
Yes _____ No______

Certified by:

_____________________________
Signature over printed name
C/MLGOO

Date: _____________________

SGLGB Form 4.1

Identifying Information
 Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the City/Municipal Budget Officer

(In coordination with the City/Municipal Accountant and Bookkeeper)
Remarks (pls. indicate if
Indicator Data Requirements
no data)
1. Approval of the Annual  Budget approved and submitted to the
Budget City/Municipal Budget Office before
December 31, 2017:
Yes _____ No______
 Re-enacted Budget used for FY 2018
Yes _____ No______

2. Use of Barangay  Barangay Cashbook:

Cashbook (latest report) Yes _____ No______

 Updated: Yes _____ No______

 With Bookkeeper: Yes _____ No_____

 According to COA standards:

Yes _____ No______

3. Submission of the  DV submitted:

Disbursement Voucher a. On the 10th day of every month
Yes _____ No______
b. Every month but was late once or twice
Yes _____ No______
c. Monthly but was late 3-12 times
Yes _____ No______
d. 1-11 times only
Yes _____ No______

4. Percentage increase in the  Total amount collected from fees and

local resources charges, tax collection, etc in:

CY 2017: PhP__________
CY 2018: PhP__________

5. Posting of the citizen’s  Citizen’s Charter with provisions on:

charter in the barangay
a. Barangay certification
Yes _____ No______
b. Barangay clearance
Yes _____ No______
c. Community tax certificate
Yes _____ No______
d. Barangay records, data and similar
documents
Yes _____ No______
e. Barangay facilities and properties
Yes _____ No______
f. Katarungang Pambarangay
 Yes _____ No______

 Citizen’s Charter with Vision and

Mission Statement:
Yes _____ No______

 Citizen’s Charter with feedback

mechanism:
Yes _____ No______

6. Establishment of a  Drop box: Yes _____ No______

feedback mechanism
 Test messaging or e-mails or hotlines
Yes _____ No______

 Public Assistance and Complaints Desk

Officer: Yes _____ No______

7. Enactment of a Barangay  Barangay Tax Ordinance:

Tax Ordinance Yes _____ No______

 Updated:
Yes _____ No______

Certified by:

________________________________
Signature over printed name
Budget Officer

Date: _____________________
 SGLGB Form 4.2

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the Disaster Risk Reduction and Management Officer

Remarks (pls. indicate if

Indicator Data Requirements
no data)
1. Functionality of the  Executive Order or similar creating the
Barangay Disaster Risk BDRRMC
Reduction and Yes _____ No______
Management Committee  Approved BDRRM Plan
(BDRRMC) Yes _____ No______
 Date of last meeting: ____________

2. Accomplishment rate of  Total number of activities/projects in

the activities/projects the CY 2018 BDRRM Plan: _________
reflected in the Barangay
Disaster Risk Reduction  Total number of accomplished
and Management Plan or activities/projects in the CY 2018
the Community-Based BDRRM Plan: _________
DRRM Plan
N = (Total number of activities/projects
accomplished / Total number of
activities/projects reflected in the BDRRM plan)
x 100

 Accomplishment Rate: __________ %

3. Number of drills  Earthquake: _____

conducted (earthquake,  Fire:_____
fire and others)  Others: _______

4. Establishment of an Early  EWS: Yes _____ No______

Warning System (EWS)  Link to higher LGUs:
Yes _____ No______
 Community is aware of the EWS:
Yes _____ No______

5. Number of available  First aid kit: Yes __ No__

functional disaster  Flashlight with batteries: Yes __ No__
equipment  Two-way radio / mobile phone:
Yes __ No__
 Rescue vehicle / barangay patrol:
Yes __ No__
 Generator set: Yes __ No__

Certified by:
 __________________________________
Signature over printed name
LDRRMO
Date: _____________________

SGLGB Form 4.3

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the Barangay

 Remarks(pls. indicate if
Indicator Data Requirements no data)

1. Compliance with the  Location of the BFDP Board:

Barangay Full Disclosure ____________________
Policy (BFDP)
2. Financial Any of the following:
Accomplishments reported  Post-activity report re conduct of the CY
during the conduct of the 2018 BAD indicated therein the report
Barangay Assembly Day on financial accomplishment; or
(BAD)  Financial Accomplishment Report; or
 State of Barangay Address indicated
therein the report on financial
accomplishment:
a. 1st Semester BAD:
Yes ______
No ______
b. 2nd Semester BAD:
Yes ______
No ______

3. Display of disaster-related  Signages: Yes _____ No______

signages, markers and  With instructions going to the
directional signs in evacuation center:
strategic locations Yes ____ No____
 Location of the said signages:
_____________________

4. Establishment of an  Evacuation Center:

Evacuation Center a. Owned:
Yes _____ No______
b. Designated:
Yes _____ No______
 Location of the Evacuation Center:
_____________________

5. Organization of the  Executive Order or similar creating the

Barangay Emergency Barangay Search and rescue Teams:
Search and Response Yes _____ No______
Teams or similar entities Date Issued: ______________

 Total number of Teams: _______

 Trainings conducted in the past 12

months: Yes _____ No______

Title of Trainings:
1.
2.

6. Establishment of a Day  Day Care Center: Yes _____ No_____

Care Center
 Barangay Day Care Worker:
Yes _____ No______

 Location of the Day Care Center:

___________________
7. Designation of priority  Signages pertaining to priority lanes:
lanes for the disadvantaged Yes _____ No______
sectors
8. Registration of  With Kasambahay Desk
Kasambahay Yes _____ No______

 List of registered Kasambahays:

Yes _____ No______

9. Percentage of cases settled  Total number of cases filed: ______

under the Katarungang
Pambarangay  Total number of cases settled: ______

 Percentage of cases filed: _______%

10. Maintenance of a Record of  RBI: Yes _____ No______
Barangay Inhabitants
(RBI) or similar

Prepared by:

__________________________________
Signature over printed name
Barangay Secretary

Certified by:

__________________________________
Signature over printed name
Punong Barangay

Date: _____________________

SGLGB Form 4.4

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the Local Social Welfare Development Officer (LSWDO)

Remarks (pls. indicate if

Indicator Data Requirements no data)

1. Functionality of the  Ordinance or similar creating the VAW

Violence Against Women Desk: Yes _____ No______
(VAW) Desk
 VAW Desk Person trained:
Yes _____ No______

 Submitted VAWC reports:

a. 1Q Yes _____ No______
 b. 2Q Yes _____ No______
c. 3Q Yes _____ No______
d. 4Q Yes _____ No______

Number of late submission of reports:

_______
2. Participation rate of day  Total number of children age 2-3 years
care attendance old: _______

 Total number of children age 2-3 years

old attending day care: _______

Certified by:

__________________________________
Signature over printed name
C/MSWDO

Date: _____________________
 SGLGB Form 4.5

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the City / Municipal Health Officer

Remarks(pls. indicate if
Indicator Data Requirements no data)

1. Accessibility to Health  Executive Order or similar

Care Services in the appointing/designating the:
Barangay a. Barangay Health Worker (BHW):
Yes _____ No______
b. Barangay Nutrition Scholar (BNS):
Yes _____ No______

 Location of the Barangay Health

Station / Center: ___________________

Certified by:

________________________________
Signature over printed name
C/MHO

Date: _____________________
 SGLGB Form 4.6

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the City / Municipal Planning and Development Officer
Remarks (pls. indicate if
Indicator Data Requirements no data)

1. Functionality of the  Executive Order or similar creating the

Barangay Development BDC: Yes _____ No______
Council (BDC)  Approved Barangay Development Plan
(BDP): Yes ____ No_____
 Minutes of meeting: Yes ____ No_____
 ¼ CSO membershop:
Yes ____ No_____

2. Representation of CSOs in  Executive Order or similar creating the

the Barangay Based BBIs with CSO representation:
Institutions (BBIs) a. BDRRMC: Yes ____ No_____
b. BDC: Yes ____ No_____
c. BPOC: Yes ____ No_____
d. BADAC: Yes ____ No_____
e. BESWMC: Yes ____ No_____
f. BCPC: Yes ____ No_____
g. Barangay GAD Focal Point System:
Yes ____ No_____

3. Implementation of  Approved BDP/AIP with PPAs for:

Programs, Projects and
Activities (PPAs) for the
disadvantaged sectors
4. Implementation of 
Programs, Projects, and
Activities (PPAs) on anti-
illegal drugs
a. Women Yes ____ No_____
b. Children Yes ____ No_____
c. Senior Citizen Yes ____ No_____
d. PWDs Yes ____ No_____
Anti-illegal drug prevention PPAs in
the Barangay Development Plan / AIP:
Yes _____ No______

Certified by:

__________________________________
Signature over printed name
C/MPDO
Date: _____________________

SGLGB Form 4.7

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________
 Seal of Good Local Governance for Barangay

Data to be Certified by the Chief of Police

Remarks(pls. indicate if
Indicator Data Requirements no data)

1. Presence of Barangay  Regular patrol/ronda:

Tanods Yes _____ No______

 Attended capacity building activities /

skills enhancement training/seminar:
Yes _____ No______

Certified by:

__________________________________
Signature over printed name
Chief of Police

Date: _____________________
 SGLGB Form 4.8

Identifying Information

Region : _______________________________
Barangay : _______________________________
City/Municipality : _______________________________
Province : _______________________________

Seal of Good Local Governance for Barangay

Data to be Certified by the City / Municipal Environment and Natural Resources Officer
Remarks (pls. indicate
Indicator Data Requirements if no data)

1. Functionality of the  MRF type:

Materials Recovery Facility a. Barangay-owned:
(MRF) Yes _____ No______
b. Clustered: Yes _____ No______
 Other materials recovery scheme:
a. Solid waste transfer station or sorting
station
Yes _____ No______
b. Drop-off center:
Yes _____ No______
c. Composting facility:
Yes _____ No______
d. Recycling facility:
Yes _____ No______
2. Effectiveness of the No  Ordinance or similar on No Littering Rule: Yes
Littering Rule and other _____ No______
Ordinance  Signages/markers on No Littering Rule: Yes
_____ No______
 Absence of litter and/or garbage dumps in the
barangay:
Yes _____ No______
3. Presence of a Collection  Ordinance or similar issuance on segregation
System to Ensure of wastes-at-source:
Segregation of Wastes-at- Yes _____ No______
Source
4. Organization of the  Executive Order or similar issuance organizing
Barangay Ecological Solid the BESWMC:
Waste Management Yes _____ No______
Committee (BESWMC)
 Approved Solid Waste Management
Program/Plan:
Yes _____ No______

Certified by:

_________________________________
Signature over printed name
C/MENRO
Date: _____________________