MD Monitoring Tool (page 1 of 2)

Note: Fields marked with an asterisk (*) are required fields. If not applicable, put N/A on the space/s provided.

INTRODUCTION CONSENT & CONFIDENTIALITY CLAUSE

Good morning/afternoon, my name is (MPDO’s All information contained herein shall be maintained in a secured database and shall be processed manually or electronically to track the status of the
FULL NAME). We are conducting a monitoring visit microenterprise for further monitoring in identifying appropriate assistance that can be given by SLP, to mainstream to other stakeholders/ partners, or
which aims to collect your basic information and validate to other databases of social protection/ welfare programs. Further, any controlled disclosure or transfer of any personal information or sensitive
track the status of your microenterprise as a result of personal information to development partners, evaluation firms, academe, and other stakeholders shall be in accordance with the Data Privacy Policy and
being a SLP beneficiary. May I have some of your Sharing Protocol of the program and provisions under the DPA of 2012. You have the right to object to the processing of your personal data, the right to
time for an interview? access your personal data that we will process, and the right to have your personal data corrected.

I agree to participate in this assessment visit and allow _______________________________________

my answers to be used as indicated above.
Signature over Printed Name

A. MD PARTICIPANT/ASSOCIATION INFORMATION Time Started: ______

Time Ended: ______
A.1 Location of the MD Project

______________________________________________________________________________________________________________________
House & Lot No. Street Barangay City/Municipality Province Region

A.2 Type of Enterprise* (please check) A.3 Modality/ies Provided (please check /specify) & Date Provided (mm/dd/yyyy)*
Individual Enterprise Group Enterprise SCF Date Provided: _______________ CBLA Date Provided:_____________
Association Enterprise ST-MD Date Provided: _______________ Others, specify: _____________________ Date Provided:_____________

A.4 Name of SLP Participant/Group or Association Representative* A.5 SLP Participant Unique Code
(if applicable)
______________________________________________________________________________________
First Name Middle Name L ast Name Ext.
A.6 Location of the Participant/Group or Association Representative*

______________________________________________________________________________________________________________________
House & Lot No. Street Barangay City/Municipality Province Region

A.7 Designation within SLPA (if applicable) A.8 Sex* A.9 Type of Participant* A.10 Contact Number
Male Female Pantawid Listahanan Poor SLP Means Test Poor

A.11 Name of SLP Association (if applicable) No. of Active Members No. of Inactive Members
Male: Female: Male: Female:

MD PROJECT MONITORING Date Monitored (mm/dd/yyyy):_____________ No. of Visits Made: _______

B. DETAILS OF THE ENTERPRISE (Original Enterprise)
B.1 Specific Name of the B.2 Products/Services Offered* B.3 Enterprise Status* B.4 Start Date of Operations*
Microenterprise* Product Service Operational Closed (mm/dd/yyyy)

Enumerate: B.5 Production/ Operation Cycle*

If the status is closed, check all applicable reasons:
Income was used for personal expenses Daily
Harvest was used for family consumption Weekly
Closed due to natural/man-made disaster/ Monthly
calamity Every two (2) months
Closed due to disease/pest infestation Quarterly
No established market Every six (6) months
Participant died/ passed away
Organizational Problem
Annual
If the enterprise has scaled-up, enumerate the additional
Financial Problem Every two (2) years
products/services offered (if applicable): Others, please specify:
Unmotivated participant/members
Others, please specify:
________________________________ ___________________
PSIC Code (input code):_________
B.6 Gross Sales* B.7 Cost of Sales* B.8 Gross Profit* B.9 Operating Expenses* B.10 Net Income/ Loss*
PhP PhP PhP PhP PhP

B.11 Buyers* B.12 Means of Verification* (check all apply)

Nature of Nature of Financial Reports
Name of Institutional Buyers Business(input Name of Traditional Buyers Business(input Operations Reports
PSIC Code) PSIC Code) Marketing Agreements
Documentation of Products/Services
1. 1. Key documents/Certification (e.g. MOA,
contracts)
2. 2. Others, please specify:
3. 3. ________________________________
B.13 Assets for MD Project Use* Acquired or Type of Asset Cost of Asset Name of Provider Type of Source
Code for Type of Asset (Php)
1 = Financial 4 = Social (specific name of asset) Received? (input code) (input code/specify)
(if applicable)
2 = Human 5 = Natural
3 = Physical
1.
Code for Type of Source
1 = Acquired by Association 2.
2 = Personally acquired
3 =DSWD (Other Programs) 3.
4 = Government
5 = Private
6 = CSO
4.
7 = NGO
8 = Others; please specify 5.

Notes/Remarks: (Write important notes/remarks about the original enterprise.)

MD Monitoring Tool (page 2 of 2)
Note: Fields marked with an asterisk (*) are required fields. If not applicable, put N/A on the space/s provided.
C. DETAILS OF THE ENTERPRISE (Additional Enterprise 1)
C.1 Specific Name of the Microenter- C.2 Products/Services Offered* C.3 Enterprise Status* C.4 Start Date of Operations*
prise* Product Service Operational Closed (mm/dd/yyyy)

Enumerate: C.5 Production/ Operation Cycle*

If the status is closed, check all applicable reasons:
Income was used for personal expenses Daily
Harvest was used for family consumption Weekly
Closed due to natural/man-made disaster/ Monthly
calamity Every two (2) months
Closed due to disease/pest infestation
No established market
Quarterly
Participant died/ passed away Every six (6) months
Organizational Problem Annual
If the enterprise has scaled-up, enumerate the additional
products/services offered (if applicable): Financial Problem Every two (2) years
Unmotivated participant/members Others, please specify:
Others, please specify:
PSIC Code (input code):___________ ________________________________ ___________________

C.6 Gross Sales* C.7 Cost of Sales* C.8 Gross Profit* C.9 Operating Expenses* C.10 Net Income/ Loss*
PhP PhP PhP PhP PhP

C.11 Buyers* C.12 Means of Verification* (check all apply)

Nature of Nature of Financial Reports
Name of Institutional Buyers Business(input Name of Traditional Buyers Business(input Operations Reports
PSIC Code) PSIC Code) Marketing Agreements
Documentation of Products/Services
1. 1. Key documents/Certification (e.g. MOA,
contracts)
2. 2. Others, please specify:
3. 3. ________________________________
C.13 Assets for MD Project Use* Acquired or Type of Asset Cost of Asset Name of Provider Type of Source
Code for Type of Asset (Php)
1 = Financial 4 = Social (specific name of asset) Received? (input code) (input code/specify)
(if applicable)
2 = Human 5 = Natural
3 = Physical
1.
Code for Type of Source
1 = Acquired by Association 2.
2 = Personally acquired
3 = DSWD (Other Programs) 3.
4 = Government
5 = Private
6 = CSO
4.
7 = NGO
8 = Others; please specify 5.

D. DETAILS OF THE ENTERPRISE (Additional Enterprise 2)

D.1 Specific Name of the Microenter- D.2 Products/Services Offered* D.3 Enterprise Status* D.4 Start Date of Operations*
prise* Product Service Operational Closed (mm/dd/yyyy)

Enumerate: D.5 Production/ Operation Cycle*

If the status is closed, check all applicable reasons:
Income was used for personal expenses Daily
Harvest was used for family consumption Weekly
Closed due to natural/man-made disaster/ Monthly
calamity Every two (2) months
Closed due to disease/pest infestation Quarterly
No established market
Participant died/ passed away
Every six (6) months
Organizational Problem Annual
If the enterprise has scaled-up, enumerate the additional Every two (2) years
products/services offered (if applicable): Financial Problem
Unmotivated participant/members Others, please specify:
Others, please specify:
PSIC Code (input code):_________ ________________________________ ___________________

D.6 Gross Sales* D.7 Cost of Sales* D.8 Gross Profit* D.9 Operating Expenses* D.10 Net Income/ Loss*
PhP PhP PhP PhP PhP

D.11 Buyers* D.12 Means of Verification* (check all apply)

Nature of Nature of Financial Reports
Name of Institutional Buyers Business(input Name of Traditional Buyers Business(input Operations Reports
PSIC Code) PSIC Code) Marketing Agreements
Documentation of Products/Services
1. 1. Key documents/Certification (e.g. MOA,
contracts)
2. 2. Others, please specify:
3. 3. ________________________________
D.13 Assets for MD Project Use* Acquired or Type of Asset Cost of Asset Name of Provider Type of Source
Code for Type of Asset (Php)
1 = Financial 4 = Social (specific name of asset) Received? (input code) (input code/specify)
(if applicable)
2 = Human 5 = Natural
3 = Physical
1.
Code for Type of Source
1 = Acquired by Association 2.
2 = Personally acquired
3 =DSWD (Other Programs) 3.
4 = Government
5 = Private
6 = CSO
4.
7 = NGO
8 = Others; please specify 5.

E. FORM CERTIFICATION

Accomplished by: Reviewed and Approved by:

__________________________________________ _________________________________________________ ________________

Signature over Printed Name of Monitoring PDO Signature over Printed Name of Provincial Coordinator Date