report cum application proforma for best youth / team of ... · annexure-3 report cum application...

Annexure-3

Report Cum Application Proforma for Best Youth / Team of Youth Award at the District Level

( 10th June, 2019 to 31st July, 2019)

under the Swachh Bharat Sumer Internship (SBSI) 2.0 – 50 hrs of Swachhta Activities by Youth

1. Name and address of the of the Youth / Leader of Team of Youth: Village ……………Post Office……….

Tehsil………….E-mail…………….. & Mob. No……………District………….. Pin Code……………State………..

2. Team Members (Team Members should not exceed 10 in number)

S

No.

Name of the participant Gender

Male/ Female

Date of

Birth

Mobile number

(if available)

1

2

3

4

5

6

7

8

9

10

3. Location for Internship / Swachhta Activities

State/UT :

District :

Block :

Gram Panchayat :

Village :

4. Period for Swachhta Activities : From ------------ To : --------------

5. Total No. of Hours, the Youth/ Team of Youth did Swachhata Activities = No. of Youth X Total No. of Hours they worked e.g. 5 Youth X 2 hrs each = 10 Hours

6. Details of activities undertaken from 10th June, 2019 to 31st July, 2019. The activities should be supported by press clippings, photographs, certificates from concerned department, Panchayat Pradhan, District Youth Coordinator etc.

A. IEC Activities

Awareness campaigns

a) No. of Awareness Drives conducted

b) No. of people sensitized

c) No. of hours spent *

Brief Description ( Not more than 150 words) :

Methodology ( How did you do it) - ( Not more than 150 words)

Challenges Faced - ( Not more than 75 words)

Field learning ( Not more than 75 words)

Suggestion/ Feedback ( Not more than 500 Characters/75 words)

Attach Images / Action Photographs/Videos/Press Clippings ( Maximum file size 1MB)

*(No. of Youth X Total No. of Hours they worked e.g. 5 Youth X 2 hrs each = 10 Hours)

Nukkad Nataks / Street Plays / Swachhta related Folk Song and Dance Performances

a) No. of performances conducted


a) No. of hours spent *








Swachhta Melas

a) No. of Melas organized

b) No.of people attendees









Wall paintings on public places

a) No. of walls painted

b) Estimated No. of people sensitized









Campaigns for Plastic Free Village and declaring plastic free zone

a) No. of Awareness Drives Conducted

Whether village become plastic free village

(Yes/No). Please indicate the appropriate










Door to Door visits (Sanitation / Hygiene / Toilet uses / Handwash)

a) No. of households visited










Conducting village / School level Rallies

a) No. of rallies conducted










Movie Screenings

a) No. of screenings organized

b) No. of attendees









B. Solid Waste Management (SWM )

Waste Collection Drives for households and common as shared spaces

a) No. of households/ public spaces waste

collected from

b) No. of people who participated









Segregation of solid waste into non-biodegradable waste

a) No. of segregation demonstrations

undertaken

b) Total No. of people who attended









Development of Compost Pits

a) No. of pits dug along with community

participation

b) No. of community people participated









Transportation of household waste (to appropriate disposal sites)

a) No. of households covered

b) No. of village people involved









Street Cleaning, Drain Cleaning, Cleaning of back alleys

a) Length of streets/ drains/ alleys cleaned

b) No. of community participants









Total No. of Youth Participated in Swachhta Activities: ………………….

Total No. of people sensitized :………………………..

Total No. of hours spent: ………………………………

7. A write up on the activities undertaken by the Youth/ Team of Youth not exceeding 1000 words, to be

attached along with the application. It may be typed or neatly hand written. (Please enclose)

8. The application should be duly supported by action photographs, videos and press clippings

9. Additional information, if any

Certified that the above details and information are correct and true.

Signature of the individual Youth / Team Leader

Place :

Date :

(The Youth/ team of youth who have been short listed for award by the committee, should be visited by District Nodal Officer to verify their

claims & credentials)

It is certified that the Youth Club/ work location was visited by me and the details provided in this proforma are

found to be correct and the same have been verified.

Signature ___________________ Name of the District Youth Coordinator ____________

Place : ________ District NYK _____________________ Date : _________ State _____________________

Annexure- 5

Nehru Yuva Kendra --------------------------------

Best Youth / Team of Youth Award at District Level

under Swachh Bharat Summer Internship (SBSI) 2.0 – 50 hrs of Swachhta Activities (10th June, 2019 to 31st July, 2019)

Brief Note to the Selection Committee Members

To encourage and support the growth of Youth Clubs & empowerment of youth and reward selfless services

rendered by them in the field of community development and Nation Building through voluntary labour, the

Department of Drinking Water & Sanitation, Ministry of Jal Shakti, Government of India has introduced the ‘Award to

Youth / Team of Youth’, at the district level under Swachh Bharat Summer Internship (SBSI) 2.0 – 50 hrs of

Swachhata (10th June, 2019 to 31st July, 2019)

The objective of the programme is to involve youth in Swachhata related activities on a large scale all over the

country. This will not only develop the personality and leadership qualities of the youth but also promote the spirit of

''dignity of labour''.

At the district level, three awards to Youth/ Team of Youth will be given. First award will be a Certificate and

Rs. 30,000/- as Cash award, the Second prize would be a Certificate and Rs. 20,000/- as Cash award and the third

prize would be a Certificate and Rs. 10,000/- as Cash award.

Those Youth/ Team of Youth, which are affiliated with District Nehru Yuva Kendras, NCC and NSS are eligible to

apply. The programmes and activities conducted and services rendered by the Youth/ Team of Youth during the

period from 10th June, 2019 to 31st July, 2019, are to be considered for evaluation.

The applications received from various Youth/ Team of Youth will be evaluated by a Committee. The process of

evaluation in the selection of Youth /Team of Youth for award should be as per the Guidelines of SBSI 2.0 dated 24 th

June, 2019. The selection committee constituted for the purpose is to select the best three Youth/ Team of Youth

from ---- such applications received from the district.

The process of evaluation in the selection of Youth/ Team of Youth for the award, as per the guidelines, would be as under:

i. The committee will not only assess the quantitative achievements w.r.t number of activities, number of youth involved, number of people sensitized and number of hours the youth worked for Swachhata activities, but it will also asses the qualitative achievement (outcome) during 50 hours project. For example, if a team of youth devote 50 hours and establish a Gobar Gas Plant in the village for energy saving. The committee may consider the visible output of the team members.

ii. Each member of the committee will have one evaluation sheet for each Youth/ Team of Youth

iii. In case of a tie, the Chairman of the committee will decide on the winner on the basis of the write up, Action Photographs, Videos & Press Clippings, which would be submitted along with the application.

Nehru Yuva Kendra -----------------

Best Youth / Team of Youth Award at District Level

under Swachh Bharat Summer Internship (SBSI) 2.0 – 50 hrs of Swachhta Activities

(10th June, 2019 to 31st July, 2019)

Assessment Sheet for evaluating performance of Youth/ Team of Youth

Name of Youth / Team of Youth:………………………………

Address…………………………………

Sr.

No

Broad Subject / issues Evaluation

Excellent / Very good / good /

insignificant

Points earned

1. Awareness campaigns

2. Nukkad Nataks / Street Plays / Swachhta

related Folk Song and Dance Performances

3. Swachhta Melas

4. Door to Door visits (Sanitation / Hygiene /

Toilet uses / Handwash)

5. Conducting village / School level Rallies

6. Wall paintings on public walls

7. Movie Screenings

8. Waste Collection Drives

9. Segregation of solid waste

10. Development of Compost Pits

11. Transportation of household waste (to

appropriate disposal sites)

12. Street Cleaning, Drain Cleaning, Cleaning of

back alleys

Sr.

No

Broad Subject / issues Evaluation

Excellent / Very good / good /

insignificant

Points earned

13. 1 Any other Programmes (Please Specify)

14. 1 Any other activity of significance (i) (ii)

Total

Total Points earned

Note : The process of evaluation will be as under :

1. Each member of the committee will have one sheet for each youth/ team of youth.

2. In case of a tie, the Chairman of the Committee will decide on the winner on the basis of the resume which would be submitted alongwith the application.

Name of the Selection Committee Member: _____________________ Signature: __________________

(with date)


Best Youth / Youth / Team of Youth Award at District Level


(10th June, 2019 to 31st July, 2019)

Assessment Sheet for evaluating performance of Youth / Team of Youth

Name of Youth / Team of Youth:………………………………

Address: …………………………………

Sr.

No

Broad Subject / issues Member

I

Member

II

Member

III

Member

IV

Member

V

Member

VI

1. Awareness campaigns

2. Nukkad Nataks / Street Plays / Swachhta

related Folk Song and Dance Performances

3. Swachhta Melas

4. Door to Door visits (Sanitation / Hygiene /

Toilet uses / Handwash)

5. Conducting village / School level Rallies

6. Wall paintings on public walls

7. Movie Screenings

8. Waste Collection Drives

9. Segregation of solid waste

10. Development of Compost Pits

11. Transportation of household waste (to

appropriate disposal sites)

12. Street Cleaning, Drain Cleaning, Cleaning of

back alleys

Sr.

No

Broad Subject / issues Member

I

Member

II

Member

III

Member

IV

Member

V

Member

VI

13. Any other Programmes (Please Specify)

14. Any other activity of significance (i) (ii)

Total

Total Points earned

Signature of Selection Committee Members (with date): 1. __________________ 2. ___________

3. ________________ 4. ___________________ 5. ________________________ 6._______________________


Best Youth / Youth / Team of Youth Award at District Level


(10th June, 2019 to 31st July, 2019)

ATTENDANCE

Meeting of the --------------- level Selection Committee held on -------------- at -------- am/ pm at the office of ------

-----

Members Present:

Name Designation Signature Telephone

1. _____________________ __________________ __________________ _ ____________

2. _____________________ __________________ __________________ _______________

3. _____________________ __________________ __________________ _ ________________

4. _____________________ __________________ __________________ __ _______________

5. _____________________ __________________ ______________ _____________________

6. ____________________ __________________ _________________ ____________________

CHAIRPERSON:

(Name) ________________________ and Designation _________________________

(Signature)

Telephone:____________________________

Annexure - 2

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