# **Attachment 2: Sample Application Screening Form for MSEs**[^1]

*\[To be completed by the credit officer\]*

Number: Environmental
classification:[^2]­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Financial entity:

Name of credit officer:

Place and date of processing:

Is this category of microenterprise, in general, expected to have
potential adverse impacts?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*\[To be completed by the microentrepreneur\]*

## A. General information

1\. Name

2\. Address

3\. Activity

4\. Location of the enterprise (lot, settlement, town, district,
province, etc.)

5\. Area: (a) rural (b) urban (c) semirural

6\. Zone: (a) industrial (b) residential (c) commercial

## B. Description of the enterprise

7\. Number of employees (including family members)

8\. Use of the premises: (a) workshop-house (b) workshop-store (c)
workshop only

9\. Products manufactured in order of importance

10\. Services provided for clients

11\. Machinery and equipment used (number of units, types, age in years)

12\. The company performs the following activities: gluing, painting,
polishing, dying, stamping, smelting, welding, applying lead, type
setting, diluting acids, tanning, washing, rinsing, galvanizing, etc.
(mark the activity)

## C. Possible impacts on personnel and family

13\. What raw materials and other inputs are used (glues, solvents,
catalysts, preservatives, etc.)? What quantities are used each month?

14\. Do you know if any of the products used contain toxic substances?
If so, what are the products and the toxic substances they contain?

15\. Are combustibles kept out of the sun?

16\. What other precautions do you usually take at your workplace to
prevent injury to health?

17\. Do your employees use protective gear (mark the equipment used)?

> \(a\) masks (b) goggles (c) earplugs (d) hard hats (e) gloves (f)
> protective clothing (g) respirators (h) boots

18\. Do you have first aid equipment? Yes ( ) No ( )

19\. Who knows how to use the first aid equipment?

20\. Do you have a properly charged fire extinguisher? Yes ( ) No ( )

21\. Do you and your employees know how to use it? Yes ( ) No ( )

22\. If you use substances that could be harmful to health do you keep
them in a safe place out of the reach of children? Yes ( ) No ( ) Do not
use ( )

## D. Impact on water resources

23\. Is there potential for contaminating ground water with oil or
chemical spills from your operations?

24\. Could your operation result in degradation or contamination of
ground or surface water?

25\. Does your used water contain contaminating substances? Please list
them (none, alkalies, acids, coloring agents, oils, poisonous
substances, etc.)

26\. How do you dispose of your liquid waste (acids, oils, toxic
substances, etc.)?

> a\. Pour it untreated down the drain
>
> b\. Treat it prior to pouring them down the drain
>
> c\. Dump it in the ground
>
> d\. Place it in the garbage in sealed containers
>
> e\. Reuse it
>
> f\. Sell it or give it away for recycling

27\. If you have a system for the treatment of liquid waste or used
water, please describe it.

28\. Where do you dispose of waste: (a) down the drain (b) in a ditch or
river

29\. Do you create areas of standing water?

## E. Impact on consumers

30\. Do the products you make contain any toxic substance that could
pose a risk to consumer health? If so, have you affixed a warning to the
packaging? Have you posted warning notices in your premises?

31\. Are your inputs, products, or processes registered with the
competent authorities (e.g. health permit, permits for certain
substances)? Please list them.

## F. Local noise, air and soil impacts

32\. Is there housing nearby? Yes ( ) No ( )

33\. Do you produce noise that disturbs your neighbors? Yes ( ) No ( )

34\. Do you have a noise-reduction system?

35\. Does your operation produce gas or foul odors that affect
neighbors? If so, do you use any system to attenuate them? Please
describe.

36\. Do you work during the night? Yes ( ) No ( )

37\. Do you have trash collection? Yes ( ) No ( )

38 If not, how do you dispose of your trash? (a) burn it (b) dump it (c)
bury it (d) dump it in a river

39\. Does your trash contain chemical waste? Yes ( ) No ( )

40\. Do you reuse or sell any of your scrap or waste? Yes ( ) No ( )

41\. Could your operation result in degradation or contamination of
soils?

## G. Sector-specific questions

42\. Entrepreneurs should respond to any sector-specific questions at
this point. (See sector fact sheets for examples.)

## H. Support institutions

43\. What is your enterprise's source of water?

44\. What is its water consumption level and cost? Could these be
reduced?

45\. Do you belong to a business association? Please give the name(s)

46\. Do you know a company, institution or professional who can advise
you on reducing environmental and health problems? If yes, please give
the name(s).

## I. Additional information or comments

I formally declare the above information to be true.

*(Signature of the microentrepreneur)*

Comments by the business support service, credit provider, or technical
service agency:

Comments by the IFI:

[^1]: Adapted from IADB 1997.

[^2]: Based on potential to have adverse environmental impacts.