ANNEX 1: ENVIRONMENTAL AND CLIMATE CHANGE SCREENING FORM
Please type or print clearly, completing this form in its entirety. You may provide additional
information on a separate sheet of paper if necessary. Kindly note that the information you
are to provide is required by Section 19of the National Environment Act, 2019 (to be filled
by the Environment focal point person at sub-county level or Environment officer at the
District/ Municipal level)
PROJECT DETAILS:
Name of the Project……………………………………………………………………
The sector of the Project………………………………………………………………….
User Department…...…..................................................................................................
Location Coordinates ……………………………………….……………..............
Village...................................................... Parish...........................................................
Lower Local Government/ District where the project is located..................................
1. Brief Project Description
a) Please provide information on the type and scale of the project (project area, area of
required land, the approximate size of total building floor areas, etc) …….
b) Will the project/ facility require auxiliary facilities? YES …..No …..If YES, please
include the type of auxiliary /ancillary facilities required ………
2. The Natural Environment
c) Describe the land formation, topography, vegetation in/adjacent to the project area
(e.g. is it a low lying land, waterlogged, rocky, swampy or wetland, etc.,)
Estimate and indicate whether vegetation might need to be cleared ……..
d) Are there any environmentally sensitive areas or threatened species that could be
adversely affected by the project (specify below)?
i. Forest Yes……No ……..
ii. Wetlands Yes …..No ……..
iii. Water Yes ……No ……..
iv. Habitats of endangered species protected by laws Yes ……No ……..
v. Land Yes ……No ……..
vi. Others (describe). (e.g cultural sites, burial places, etc.,) Yes …..No ……..
3. Wetland System
a) How far is the nearest wetland from the project site? ……………km
b) Will the project adversely affect a wetland system? Yes…….No ……
4. Rivers and Lakes Ecology
Is there a possibility that due to construction and operation of the project the river and
lake ecology will be adversely affected? Attention should be paid to water quality and
quantity; the nature, productivity and use of aquatic habitats, and variations of these over
time. Yes ………No ……..
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5. Geology and Soils
Based on visual inspection or available literature, are there areas:
a) Of possible geologic or soil instability? Yes ……..No ………
b) Does that have risks of large scale increase in soil salinity? Yes …….No ………
6. Ground Water
Will the project require groundwater? Yes …….No …….
If yes, does the project have plans for catchment protection?………
7. Air pollution
Will the project release pollutants into the atmosphere? Yes …….No …….
8. Noise Pollution during Construction and Operations
Will the operating noise level exceed the allowable noise limits? Yes ……No ……
9. Solid or Liquid Wastes, including Medical Waste
a) Will the project generate solid or liquid wastes, including medical waste? Yes/No
If “Yes”, how will it be handled? ……..
b) Will the project involve latrines, septic, soak pit or sewerage systems? Yes…No.
c) What is the estimated distance of the pit latrine from the nearest water source?
(Please note that the distance should not be less than 50 meters?………..
10. Access and Use of Local Resources
a) Will the project affect access to natural resources? Yes ……No …….
b) Will there be additional demand for local resources (e.g. water supply, sanitation
facilities, health centres, lodging, etc.)? Yes ……..No ………
11. Pesticides, Insecticides, Herbicides or any other Poisonous or Hazardous Chemicals
a) Will the project require the use of such chemicals? Yes …..No ……..
b) If “Yes”, how will the chemicals be handled? …………
12. Petroleum-based Fuels or Bi-products
a) Will the project use petroleum-based fuels? Yes ………No ……..
b) Will the project use petroleum-based bi-products like bitumen?Yes ……..No …….
13. Health and Safety
a) Will the project safeguard worker's health and safety? Yes …….No ……..
If yes, specify the measures in place to safeguard human health and safety.
b) Will the project activities affect the community's health and safety? Yes….No ….
If yes, specify the measures in place to safeguard human health and safety.
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14. Climate Change
a) Is the project location susceptible to earthquakes, landslides, flooding, erosion, or
extreme weather conditions that could affect the project? Yes….. No…………………….
b) If YES, does the project have measures in place to mitigate or adapt to the negative
consequences of climate change? …………
15. Historical, Archaeological or Cultural Heritage Site
a) Based on available sources, consultation with local authorities, local knowledge and/or
observations, could the sub-project alter any historical, archaeological or cultural
heritage site or require excavation nearby? Yes …..No ……..
b) If YES, provide an additional description, possible alternatives reviewed and /or
appropriate mitigation measures considered ……..
16. Land use, Resettlement and/or Land Acquisition
a) Are there any land use plans on or nearby the project location, which will be negatively
affected by project implementation? YES/No………………
b) Will involuntary resettlement, land acquisition, or loss, denial or restriction of access to
land and other economic resources be caused by the project implementation? Yes …No
17. Loss of Crops, Fruit Trees and Household Infrastructure
Will the project result in permanent or temporary loss of crops, fruit trees and household
infrastructure (such as granaries, outside toilets and kitchens, etc.)? Yes ….. No ……..
18. Landscape/Aesthetics
Is there a possibility that the project will adversely affect the aesthetic attractiveness of
the local landscape? Yes …….No ……..
19. Vulnerable people
a) Will the project employ the local community? Yes…..No …..
b) Will the project displace historically disadvantaged people? Yes ……No …….
c) Will the project sensitize on HIV and AIDS? Yes …….No …….
d) Will women and youth be considered for employment? Yes ……No ……
e) Will the project lead to gender-based violence? Yes …….No …….
f) Will the project lead to violence against children? Yes …….No …….
g) Will the project employ child labour? Yes ……..No…….
20. Grievance Redress
h) Will the project have a grievance redress mechanism? Yes ………No ……..
EVALUATION
1. Produce significant amount of pollutants: Yes [ ] No [ ]
2. Type of pollutants (if yes in 1): Air [ ] Water [ ] Ground [ ]
3. Negative impacts in large scale: Yes [ ] No [ ]
4. Irreversible destruction of fragile system: Yes [ ] No [ ]
5. Depletion, displacement or extinction of protected species: Yes [ ] No [ ]
6. Negative impacts whose mitigation requires consultation: Yes [ ] No [ ]
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7. Negative cumulative impacts in foreseeable future: Yes [ ] No [ ]
8. Noncompliance to social policy: Yes [ ] No [ ]
9. Need for further studies: Yes [ ] No [ ]
RECOMMENDATIONS:
Based on the above screening results, the following recommendations are made;
Before construction/civil works can commence, the following safeguard documents must
be prepared (tick as relevant)
a) ESIA …………….
b) Project Brief …………….
c) ESMP ………………….
d) RAP ………………………
PREPARED BY:……………………………………
SIGNATURE:………………………………………….
DESIGNATION:……………………………………….
DATE:…………………………..
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