PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM Survey Clearance Form 1. Title of the statistical survey/census * 2. Legal basis (optional) 3.1 Proponent agency/individual (Name and Address) * 3.2 Conducting agency (Name and Address) * 3.3 Other cooperating agencies * 3.4 Funding source/s a. RGoB b. Local private/corporations c. Foreign/DP 3.5 Consultants 4 Objectives and relevance of the survey (Cite specific use of the data to be collected, or programs/issues to be addressed) * 5.1 Status of survey New (proceed to 5.3) Existing (Proceed to 5.2) 5.2 Status of survey form/questionnaire Existing form for clearance a renewal with revision Existing form for clearance renewal without revision. Give previous clearance no. 5.3 Is this survey a rider to another survey * No Yes (Specify)Yes (Specify) 5.4 Is this survey a component of a national or international program? * No Yes (Specify)Yes (Specify) Name of the Applicant * Designation * Contact Number * Email Address * Date * NOTE: * Submit If you are human, leave this field blank.
