version: wholesale/retail track, 0 employees, emerging marketcm6.2 what % of profits or sales was...

Example Company Impact Assessment (In Progress)Version: Wholesale/Retail Track, 0 Employees, Emerging Market

Tue Feb 21 18:29:06 GMT 2012

Governance

Corporate Accountability

Mission & EngagementGV2.1 Does your company have a corporate mission statement, and does it include any of the following: [Equally Weighted]

No written statement A written corporate mission statement that does not include a social or environmental commitment A commitment to social impact (including poverty alleviation) A commitment to environmental stewardship and conservation

GV2.4 Are there key performance indicators (KPIs) or metrics that your company tracks on at least an annual basis todetermine if you are meeting your social or environmental objectives? [Equally Weighted]

We don't track key social or environmental performance indicators We measure KPIs/metrics or outputs that we have identified and defined in order to determine if we are achieving

our social and environmental objectives We measure social and environmental outcomes over time (examples: 3rd-party studies, customer or household

surveys, progress out of poverty index, etc.)

GV2.5 Separate from a mission statement, has your company legally ensured that its social or environmental mission will bemaintained over time, regardless of company ownership? If yes, describe in the text box below. If no, select N/A. [NotWeighted]

N/A

GovernanceGV3.1 Which of the following governance structures does your company have? (Select one) [Equally Weighted]

Owner/Manager governed Governing Body/Advisory Body Board of Directors

GV3.2 Which of the following characteristics does your board or governing body have (check all that apply)? If no board orgoverning body, select None. [Equally Weighted]

None Has at least one independent member At least 50% independent members Meets at least twice annually (2x per year) Our company is a cooperative and elects its board from membership

GV3.3 Does your Board of Directors or governing/advisory body have written responsibility for the following issues? (Check allthat apply) Select None if you do not have a Board of Directors or governing/advisory body. [Less Weighted]

None Guiding corporate strategy, setting strategic goals and major plans of action Approving annual budgets, overseeing major capital expenditures and general risk management Overseeing executive compensation Overseeing the company's social and environmental mission, with specific goals and targets (if no mission

statement, do not select this option) Other

Anti-CorruptionGV4.2 Does your company have one of the following policies regarding work conduct (Check only one): [Less Weighted]

None A written Code of Business Conduct that explicitly establishes behavioral expectations for the organization A written Code of Business Conduct that explicitly establishes behavioral expectations for the organization and

that includes a statement against bribery and corruption.

GV4.3 If your company has a Code of Business Conduct, which of the following groups receive a copy and instruction regardingyour corporate policy? If you answered no to the question above, select None. (Check all that apply) [Equally Weighted]

None Owners Managers Non-Managerial workers Board or governing/advisory body

Transparency

TransparencyGV5.1 During last FY, with which financial reporting standards did your company comply? [Heavily Weighted]

IFRS (International Financial Reporting Standards, via the International Accounting Standards Board) GAAP (Generally Accepted Accounting Principles, via independent U.S. standards body) Local accounting standard (via local independent standard setting body) Other (describe) None of the above N/A Our company is pre-revenue

GV5.2 Were your company's financial statements from last FY: [Equally Weighted]

Neither Audited or Reviewed Reviewed Audited

GV5.3 If your company's financial statements were audited or reviewed, what type of individual or entity conducted that review?If you selected None for GV5.2, select None here. [Less Weighted]

None/ Neither Audited nor Reviewed Locally-accredited auditing firm or CPA/CFA Internationally-accredited auditing firm or CPA/CFA

GV5.5 Is the product or service made or sold by your company covered by a warranty or a client protection policy forconsumers? Select N/A only if your company provides consulting services. [Less Weighted]

Yes No N/A

GV5.6a Is there a publicly-known mechanism through which customers can provide product feedback, ask questions or filecomplaints? [Less Weighted]

Yes No

Governance Metrics

Governance MetricsGV1.1 Reporting Period: On what date did your last fiscal year end? [Not Weighted]

GV1.2 Currency: What currency did you use for financial reporting during the last fiscal year? Use this currency to report on allcurrency-related metrics. [Not Weighted]

GV1.3 Total Earned Revenue: Report your company's total revenues from the last Fiscal Year (FY). [Not Weighted]

GV1.4 Total Cost of Goods Sold (COGS): Report Total COGS from the last FY [Not Weighted]

GV1.5 Total Non-Labor Expenses from last FY [Not Weighted]

N/A

GV1.6 EBIT (Earnings Before Interest & Taxes) [Not Weighted]

GV1.7 Net Income: Report your net income from the last FY [Not Weighted]

GV1.8 Total Taxes paid during last FY [Not Weighted]

Community

Community Metrics

Community MetricsCM1.5 How many Significant Suppliers did your company work with during the last FY? Significant Suppliers are your largest

suppliers that collectively represent approximately 80% of your purchases in currency terms. [Not Weighted]

CM1.6 How many Significant Distributors or Retailers did your company work with during the last FY? If your company does nothave a distribution model (only direct sales or service offerings), enter N/A. [Not Weighted]

N/A

CM1.7 During the last FY, what was the value of purchases from supplier organizations that were sourced locally (within 200miles/322 km of your operations)? Estimates within +/- 10% are acceptable. [Not Weighted]

CM1.8 What was the total amount (in currency terms) allocated for charitable-giving purposes during the last FY? If this is nottracked or unknown, enter 0. [Not Weighted]

CM1.9 What were the total number of hours dedicated to charitable activities, community service, and other volunteer activitiescontributed across the company during the last FY? If your company does not track this metric, select N/A. [NotWeighted]

N/A

CM1.10 What type of customer/client does your company target? [Not Weighted]

Individuals Households Communities Business to business (B2B) Government Non-Governmental Organizations Other

CM1.11 How many customers/clients served in the last fiscal year? Provide the number for each type of client served selected inthe metric above. [Not Weighted]

CM1.12 What is the unit of measure for reporting on your company's units sold, produced, exported, or installed by theorganization. Choose from the following: [Not Weighted]

CM1.13 How many of the above product or service units/volume were sold during the last fiscal year? Enter each unit type andthe number in the text box below. [Not Weighted]

CM1.14 List any third-party certifications for products/services that are currently valid for your company, its products or services,or its production and management methods. [Not Weighted]

N/A

Community Practices

Suppliers & DistributorsCM2.1 During the last FY, what % of the products (on currency basis) your company manufactures or sells had a product

certification or production process certification? For service providers, what % services provided were performed byaccredited providers? If None, enter 0. [Equally Weighted]

CM2.2 Does your company have a tracking system in place for all products to manage quality assurance issues? Select N/Aonly if no physical product is involved. [Equally Weighted]

Yes No N/A

CM2.3 As part of your company's selection process, is the social and environmental performance and impact of suppliers,distributors or retailers taken into consideration? Select the options that represent the screening(s) a majority of yourdistributors, suppliers or retailers go through: [Equally Weighted]

None Significant suppliers, distributors and retailers are screened for specific negative practices (ie - no child labor, no

negative environmental impacts) Significant suppliers, distributors and retailers are screened for positive impact (environmentally-friendly

manufacturing process; excellent labor practices, etc) Other (describe)

CM2.4 When evaluating the on-going social and environmental performance of Significant Suppliers, which of these policies arefollowed? [Equally Weighted]

None A majority of Significant Suppliers provides social and environmental reporting or auditing to your company on an

annual basis A majority of Significant Suppliers adhere to specific social and environmental performance standards that are

best-in-class for your industry (ISO, SA8000, etc) Other (describe)

CM2.5 What is the average tenure of your relationships with Significant Suppliers? [Equally Weighted]

Less than 12 months 13 -36 months 37 months - 60 months 61 months +

CM2.6 During the last FY, with what % (on currency basis) of your Significant Suppliers did you conduct on-site visits? [EquallyWeighted]

CM2.7 During the last FY, with what % of your Significant Distributors/Retailers (on currency basis) did you conduct on-sitevisits? Select N/A only if your company does not distribute or sell via distributor/retailers. [Equally Weighted]

N/A

CM2.8 During the last FY, what % of your Significant Suppliers (on currency basis) had internationally-recognized productcertifications? Enter 0 if you do not know whether your Significant Suppliers are certified. [Equally Weighted]

CM2.9 Is the payment of a fair or living wage to workers for a majority of Significant Suppliers verified or certified? Select onlyone. [Equally Weighted]

Neither verified nor certified Verified by the company Certified as part of a product or production process certification or certified by another third-party Other (describe)

Local InvolvementCM3.1 Excluding labor, what % of your total expenses were sourced from suppliers located within 322 km/ 200 miles from your

operations during the last FY? [Equally Weighted]

CM3.2 Are a majority of your customers based or live within 322km/ 200 miles of your company's headquarter or productionfacilities? [Equally Weighted]

Yes No

CM3.3 Does your company routinely engage with and seek feedback from the local community about the company's businessactivities and social/environmental performance? If yes, select which methods are used for feedback (Check all thatapply) [Heavily Weighted]

None Through representation on the board or governing/advisory body Through community meetings that occur at least once a year Through surveys that are conducted in the local community by the company Through online forms or via the company website Other (describe)

DiversityCM4.5 What % of the company is owned by individuals who are women or individuals from chronically-underemployed

communities? [Equally Weighted]

CM4.6 What % of the members of your Board of Directors or other governing/advisory body is women or individuals fromchronically underemployed communities? Select N/A only if your company is governed by an owner/manager structureand does not have a Board of Directors or governing body. [Equally Weighted]

N/A

CM4.7 What % of the company is owned by a non-profit organization (i.e. owns stock, stock equivalents, or stock options in thecompany)? [Less Weighted]

Civic Engagement & GivingCM6.1 Has your company provided financial or in-kind support (donations of time or other in-kind contributions) to any of the

following during the last FY? [Equally Weighted]

Local non-profits Local schools/hospitals/health clinics Scholarship program at local school/university Museums, cultural and community centers Church/religious organization Other (describe) None

CM6.2 What % of profits or sales was donated to community outreach initiatives during the last FY? [Equally Weighted]

Unknown/ not tracked 0% 1-4% of profits or 0.1-0.4% of sales 5-9% of profits or 0.5-0.9% of Sales 10-50% of profits or 1-5% of sales >50% of profits or >5% of sales

CM6.3 Does your company have membership or a civic partnership with any of the following types of organizations? (Check allthat apply) [Less Weighted]

None Business or Trade Associations Chamber of Commerce Governmental Institutions Local academic institutions Cooperatives Other (describe)

CM6.4 Has your company worked within its industry to develop or advocate for increased social and environmental standards orproduct regulation for your industry during the last 12 months? [Less Weighted]

Yes No

CM6.5 Have these efforts resulted in a specific institutional, industry or regulatory reform? (Select N/A if your answer to CM6.4was No) [Less Weighted]

No Yes, reforms are in process (not yet implemented) Yes, reforms have been implemented at the federal/regional/municipal level Yes, reforms that impact industry standards through private (non-public sector) initiatives. N/A

Environment

Environmental Practices

Land, Office, PlantEN2.1a Does your company have an environmental management system that includes any of the following? (Check all that

apply) [Heavily Weighted]

Internal or external assessment undertaken of the environmental impact of your company's business activities Periodic compliance and auditing to evaluate impact of activities Policy statement documenting the company's commitment to the environment Stated objectives and targets exist for environmental aspects of your company operations Resources allocated to target reductions Other (describe) None

EN2.2 Has your company gone through an environmental review or audit during the last 12 months? If yes, select what type ofaudit or review was conducted; if no, select no. [Equally Weighted]

No Internal Review 3rd party-conducted review 3rd party-conducted audit Other (describe)

EN2.3 Does your company have any of the following recycle/reduce/reuse programs? (Select only one) [Equally Weighted]

Company recycles and reuses materials on premises, with clearly-marked bins for use A written recycle/reduce/reuse policy that is posted at plant facilities with clearly-marked bins Other (describe) None

EN2.4a Which best describes your company's office and/or plant facilities? [Equally Weighted]

Located in newly constructed building Located in previously-constructed building

EN2.5a Which best describes a majority of the company's offices and plant facilities' environmental efficiency (also known as"green building practices"): [Equally Weighted]

Buildings are LEED certified or LEED equivalent certified Building construction and/or operations make use of sustainable materials (e.g. reclaimed products) Buildings employ energy saving strategies (e.g. energy use monitoring, efficient appliances and lighting,

renewable energy use) Buildings use systems for increasing water efficiency (e.g. water efficient appliances, fixtures, and landscaping) Buildings use systems to monitor and improve air quality (e.g. increased ventilation, access to natural daylight) New building sites are chosen based on sustainability considerations (e.g. minimizing impact on ecosystems and

waterways) Other (describe) None

EN2.6a If your company bought any new equipment during the last 12 months, was any of it energy efficient equipment or otherenvironmentally-friendly equipment? Select N/A if no capital expenditures were made during the last 12 months. [LessWeighted]

Yes No N/A

InputsEN3.1 Is environmental sustainability integrated into the design and production process? (Select N/A if your company does not

design or produce a product). [Equally Weighted]

Yes No N/A

EN3.2 During last FY, what % of your products sold had a product certification that assesses the environmental impacts of theproduct/production process for that product? Select N/A only if there is no physical product being sold. [EquallyWeighted]

N/A

EN3.3 Has your company conducted any of the following during the last 24 months with regard to a majority of the products youmanufacture or sell (representing at least 50% of revenues): [Equally Weighted]

Periodic Life Cycle Assessment Cradle-to-Cradle certification Product has been source reduced Product has gone through toxicity reduction exercise None

EN3.4a What is the % of recycled, biodegradable, or environmentally-preferred/sustainable materials in the product (includingpackaging)? If unknown, enter 0. [Equally Weighted]

EN3.5a Has your company implemented any of the following water conservation methods at your corporate office or plantfacilities? (Check all that apply) [Equally Weighted]

Harvest rainwater Water recycling/reuse during the production process Low-flow faucets/taps, toilets, showerheads Other (describe) None

EN3.6 From what sources does your company get its electricity? Check all that apply. [Equally Weighted]

Diesel-generators Municipal power grid (sources unknown/not renewable) Municipal power grid (at least 10% of municipal power is generated from renewable sources) Bio-fuel or other clean/renewable based generators Renewable energy sources (including on-site renewable) Other (describe)

EN3.7a Does your company monitor and record its energy usage? [Equally Weighted]

We do not currently monitor and record our usage Our company monitors and records usage (no reduction targets) Our company monitors usage and has specific reduction targets Our company monitors usage and has met specific reduction targets during the last FY

EN3.8 During the last FY, what % of energy used by your company came from renewable sources? (include on-site renewablegeneration) If none, or if you don't know, enter 0. [Equally Weighted]

OutputsEN4.1a How does your company dispose of non-hazardous waste/garbage? [Equally Weighted]

Incinerate/burn/on-site disposal (uncertified) 3rd party garbage collection, no certification for disposal Municipal garbage collection Composting garbage Waste is separated and recycled; reusable waste is donated/provided to facilities that can reuse Private 3rd party disposal (that had been certified for proper disposal methods and provides documentation) On-site disposal that is compliant with internationally-accepted methods (3rd party reviewed) Other (describe)

EN4.2b During last FY, what % of non-reusable hazardous waste (batteries, paint, electronic equipment, etc.) was disposed ofresponsibly, with a documented 3rd party? (Select N/A if you do not have any hazardous waste) [Equally Weighted]

N/A

EN4.3b If your company uses any hazardous materials on site (including chemicals, pesticides, fertilizer), check all of theprocedures that your company follows: (Select N/A if you use no hazardous materials and chemicals) [Equally Weighted]

None of these procedures All containers with hazardous materials are labeled, with instructions for proper storage, use and disposal All hazardous materials are kept in sealed containers in a locked storeroom located in a separate area from

regular business activities Written procedures for safe storage, use and disposal of each hazardous material available in the local language

of work N/A - no hazardous materials on site

Transportation, Distribution & SuppliersEN5.1a Do any of your company's significant suppliers monitor and report on the following? Check all that apply [Heavily

Weighted]

Utilize renewable energy at their facilities Recycle water on-site or use a close-loop or other water recovery system Monitor waste production or GHG emissions Dispose properly of hazardous materials and provide documentation of such disposal Have implemented programs to reduce GHG emissions, waste production, or water or energy usage Other (describe) None

EN5.2a During the last FY, what % of your company's Costs of Goods Sold (less labor expenses) were procured from significantsuppliers who monitor and report on any of the above selected factors? Enter 0 if none of the factors above wereselected. [Equally Weighted]

EN5.3 Has your company implemented an environmentally-efficient shipping or distribution policy? [Less Weighted]

Yes No

EN5.4 Has your company adopted any of the following techniques for minimizing the environmental impact of its distributionand supply chain? (Check all that apply) [Equally Weighted]

Utilize clean or low-emission vehicles (including hybrid, LPG, and electric) to transport and distribute product Utilize strategic planning software to minimize fuel usage and shipping footprint Train drivers and handlers in fuel efficient techniques Utilize freight/shipping methods with lower environmental impacts (i.e. - avoiding air shipment) Other (describe) None

Socially & Environmentally-Focused Business Models

Governance Business Models

Social EnterpriseSE1.1 Does your business have a social or environmental focus to its business model and/or core structure? Below is a list of

socially- and environmentally-focused business models - chose any model that is applicable for your company orenterprise.

Yes No

Our product or service benefits consumers by providing one of the following: access to basic services,health care and products, improved economic opportunity for product users, improved market accessthrough physical or technological infrastructure, access to education, greater capital flow to non-profits orsocially-focused enterprises, or access to arts and media.

Yes No

Our product or service preserves or conserves the environment through one of the following: Providing orbeing powered by renewable energy or cleaner-burning energy than market alternatives, reducing energyand/or water use, reducing waste, promoting land or wildlife conservation, reducing toxic/hazardoussubstance and input materials, pollution prevention and remediation, or educating, measuring,researching, or providing information to solve environmental problems.

Yes No

Workers own the majority -- more than 50% -- of our company (examples: a worker cooperative or acompany that has significant ownership by many of its workers)

Yes No

Our company is a producer cooperative where owners are supplier members who organize production(examples: farmer cooperative, artisanal cooperative)

Yes No

Our company focuses on suppliers. This includes sourcing through fair wage certified suppliers, andsupporting small-scale suppliers -- companies with fewer than 50 workers or cooperatives -- by providingtechnical assistance/capacity building, entering into future contracts, or buying goods from local artisans.

Yes No

Our company uses a microfranchising or micro-distribution model. Microfranchises have on averagefewer than 10 workers, are independently owned and operated, and distribute products exclusively for theparent company. Microdistribution is a sales and revenue model that relies on network of individualsellers/retailers for whom the product comprises at least 50% of their total income.

Yes No

Our company donates at least 20% of profits to charity on an annual basis, or has created anon-profit/foundation and provides at least 50% of the operational budget for that organization.

Yes No

Our company was created as a result of a government privatization scheme (within the past 5 years) or toproduce a product in and for the local economy that previously had only been available through import(import substitution model).

Yes No

Our production practices are designed to conserve the environment across the company's entireoperations, making the company environmentally-efficient. This would include retrofitting facilities to makethem energy efficient, changing transportation/distribution to make environmentally efficient, monitoring &reducing water, waste, emissions and energy use.

Yes No

Our company does not qualify for any of the above highlighted enterprise models (If selected, skip to theend of the assessment)

Community Business Model - Products & Services Introduction

Community P&S IntroductionSE3.1 Which of the following areas does your product or service focus on? Though some products/services address multiple

issues, select the ONE most direct problem that your company's product line is designed to solve for your customers. Ifyour company has multiple product/service offerings, respond via the assessment platform for one product. During yoursurvey review, we will work to capture multiple beneficial product offerings using a weighted average approach.

Yes No

Creates access to basic services (examples: providers of electricity or products that provide electricity,clean drinking water, affordable housing, waste and sanitation systems or disposal)

Yes No

Promotes health or healthy living (examples: medical equipment, medical services and medicines,preventative health services or products, healthy living, exercise, eyeglasses, sanitary napkins products)

Yes No

Promotes education (examples: schools, text books, tutoring, career leadership training)

Yes No

Improves market access through physical or technological infrastructure (examples: mobiletelecommunications, business technologies or software, roads, bridges, railways, ports, building andconstruction materials not previously available)

Yes No

Creates economic and/or empowerment opportunities by supporting individuals in improving productivityand other income-generating activities (examples: capacity building services, job mentoring, agricultureequipment or services designed to maximize farmer productivity)

Yes No

Creates access to capital for socially-focused for-profit businesses or non-profits (examples: impactinvesting, sustainability consulting, fundraising services, products that assist in raising capital)

Yes No

Promotes arts and media (examples: independent media and arts, products that preserve local culturesuch as artisanal crafts or products made using culturally-significant or traditional production methods)

Community Business Models - Products & Services

Arts/MediaSE10.1 Please tell us more about how your product or service promotes the arts, sciences or media. [Not Weighted]

SE10.2 Which of the following product or service descriptions best fit your company? [Not Weighted]

Products or services that *support* fine arts and cultural preservation (i.e. artisanal handicrafts, ,jewelry, historicproduction methods, books)

Products or services with a core purpose of promoting arts and media (i.e. research labs, museum-quality fine art) Products/services with a core purpose of independent journalism and cause-related media These descriptions do not apply to our company's product/service (Skip the remainder of this section)

SE10.3 What % of your revenues last fiscal year were from the above products or services? [Not Weighted]

SE10.4 What is your unit of analysis for number of customers served? [Not Weighted]

Individual Household Community Business/organization

SE10.5 How many of the above-selected customers were reached in the last fiscal year by your products or services? For eachcustomer type selected, enter using numbers without commas or periods. [Not Weighted]

SE10.6 This is a calculated question based on your answer from SE10.2: Which of the following product or service descriptionsbest fit your company? 1) Products or services that *support* fine arts and cultural preservation, 2) Products or serviceswith a core purpose of promoting arts and media, OR 3) Products/services with a core purpose of independentjournalism and cause-related media. And, question SE10.3: What % of your revenues last fiscal year were from theabove products or services? [Equally Weighted]

Serving Those In NeedSE11.1 Are at least 25% of the users/customers/end beneficiaries of your product or service from under-served communities?

[Not Weighted]

Yes

No (ifNo, skiptheremainingquestionsin thissectionandproceedto thenextpage)

SE11.2 Describe the beneficiaries or end-users of your products or services and how you characterize them as underserved.[Not Weighted]

SE11.3 Which of the following underserved populations does your business target as customers or end beneficiaries of yourproduct or service? If you sell to other businesses (B2B), think of who the ultimate user of your product or service is. [NotWeighted]

Urban poor (includes low income, poor and very poor) Rural poor (includes low income, poor and very poor) Minority, previously-excluded, women, disabled, elderly or other underserved (excluding the poor) Nonprofits that serve the poor (including urban and rural low-income, poor and very poor,

minority/previously-excluded, women, disabled or elderly) Nonprofits (other than those that serve the poor)

SE11.4 What % of the end users/customers of your product or service are from all of the underserved populations selectedabove (in question 11.3)? [Not Weighted]

SE11.5 Which of the following products/services attributes assist in targeting the above selected underserved communities:[Least Weighted]

Product/service utilizes an innovative technology that adapts the product to meet the needs of the underserved Product/service utilizes an innovative distribution model to bring this type of product to populations that previously

could not access it Vendor provides training on safe use and/or maintenance of the product/service Product/service is accompanied by a zero-interest or below market- financing option (directly from company or

through finance partner) with small repayment amounts to provide the poor access to purchase Product/service pricing model includes transparent pricing for all customers Company utilizes a cross-subsidization model whereby higher pricing for middle and high-income clients

facilitates offering lower/subsidized pricing for low income clients/customers These product/service attributes do not apply to our company (Skip the remainder of this section)

SE11.6 Use the field below to describe any innovative technology, distribution or pricing models selected above. [Not Weighted]

SE11.7 This is a calculated question based on your answer from SE11.2: Which of the following underserved populations doesyour business target as customers or end beneficiaries of your product or service? Urban poor; Rural poor; Minority,previously-excluded, women, disabled, elderly or other underserved (excluding the poor); Nonprofits that serve the poor ;Nonprofits (other than those that serve the poor). And, question SE11.4: What % of the end users/customers of yourproduct or service are from all of the underserved populations selected above? [Most Heavily Weighted]

SE11.8 What % of customers/beneficiaries qualify as poor or very poor, with incomes below $2.00 per day? Estimates within +/-5% are acceptable. (See currency converter in help text to get local currency terms) [Heavily Weighted]

Basic ServicesSE4.1 Tell us more about how your product or service provides or improves access to basic services: [Not Weighted]


Products or services that are used to *support* the provision of basic services that were previously unavailable(examples: garbage removal, waste management, water testing kits/equipment, technology that sends textmessages when water is available)

Products or services that provide basic services that were previously unavailable (examples: clean drinking water,sewage previously unavailable, housing previously unavailable, private toilets, electricity previously unavailable)

These descriptions do not apply to our company's product/service (Skip the remainder of this section)



Individual Household Community Business/organization Other (describe)

SE4.5 How many of the above-selected customers were reached in the last fiscal year by your products or services? Pleaseenter for each customer type selected, using numbers without commas or periods. Estimates within +/- 5% areacceptable. [Not Weighted]

SE4.6 This is a calculated question based on your answer from SE4.2: Which of the following product or service descriptionsbest fit your company? 1) Products or services that are used to *support* the provision of basic services that werepreviously unavailable, OR 2) Products or services that provide basic services that were previously unavailable). And,question SE4.3: What % of your revenues last fiscal year were from the above products or services? [Equally Weighted]

HealthSE5.1 Tell us more about how your product or service improves health outcomes or promotes healthy living: [Not Weighted]


Products or services that promote healthy lifestyles (examples: herbal medicines/remedies, exercise programs,sanitary napkins, yoga)

Products or services that *support* basic health needs (examples: drug-tracking technologies, other products thatsupport in the safe and effective delivery of health services, clean-burning in-home cookstoves)

Products or services that treat or prevent critical illness or long-term disabilities (i.e. life-saving medical equipment& services, health clinics, pre-natal care, pharmacies, eyeglasses, contraceptives,vaccinations/internationally-approved medicines)





SE5.5 How many of the above-selected customers were reached in the last fiscal year by your products or services? For eachcustomer type selected, enter a number without commas or periods. Estimates within +/- 5% are acceptable. [NotWeighted]

SE5.6 This is a calculated question based on your answer from SE5.2: Which of the following product or service descriptionsbest fit your company? 1) Products or services that promote healthy lifestyles, 2) Products or services that *support*basic health needs, OR 3) Products or services that treat or prevent critical illness or long-term disabilities. And, questionSE5.3: What % of your revenues last fiscal year were from the above products or services? [Equally Weighted]

EducationSE6.1 Tell us more about how your product or service provides education: [Not Weighted]


Products or services that *support* education and education/professional development initiatives (examples:educational toys and creative problem-solving games)

Products or services that provide essential education coursework, advancement of knowledge, and academic orprofessional development (examples: skills/career training, primary or secondary school, university, trade school,textbooks, education software)





SE6.5 How many of the above-selected customers were reached in the last fiscal year by your products or services? For eachcustomer type selected, enter using numbers without commas or periods. Estimates within +/- 5% are acceptable. [NotWeighted]

SE6.6 This is a calculated question based on your answer from SE6.2: Which of the following product or service descriptionsbest fit your company? 1) Products or services that *support* education and education/professional developmentinitiatives (examples: educational toys and creative problem-solving games), OR 2) Products or services that provideessential education coursework, advancement of knowledge, and academic or professional development (examples:skills/career training, primary or secondary school, university, trade school, textbooks, education software). And,question SE6.3: What % of your revenues last fiscal year were from the above products or services? [Equally Weighted]

Infrastructure/Market AccessSE7.1 Tell us more about how your product or service improves infrastructure and market access: [Not Weighted]


Products or services that *support* improved market access through physical or technological infrastructure(examples: materials and equipment that were previously unavailable used to build physical infrastructure)

Products or services that deliver improved market access through physical or technological infrastructure(examples: bridges, ports, roads, mobile telecomm, financial or business software/technology, or other previouslyunavailable infrastructure)





SE7.5 How many of the above-selected customers were reached in the last fiscal year by your products or services? for eachcustomer type selected, enter using numbers without commas or periods. Estimates within +/- 5% are acceptable. [NotWeighted]

SE7.6 This is a calculated question based on your answer from SE7.2: Which of the following product or service descriptionsbest fit your company? 1) Products or services that *support* improved market access through physical or technologicalinfrastructure, OR 2) Products or services that deliver improved market access through physical or technologicalinfrastructure. And, question SE7.3: What % of your revenues last fiscal year were related to the above products orservices? [Equally Weighted]

Economic Opportunity/EmpowermentSE8.1 Tell us more about how your product or service provides or improves economic opportunity and empowerment for

individuals and/or communities: [Not Weighted]


Products/services enable a shift in focus and resources to income-generating activities as a by-product and aredesigned for another purpose (i.e.day-care, more efficient agricultural equipment, products that improve productivityof business activity)

Products/services whose core function is to create economic opportunity (i.e. microinsurance, job/skills training,leadership mentoring, new mechanism to a connect products to marketplace, products/services that directly improveproductivity/efficiency)





SE8.5 How many of the above-selected customers were reached in the last fiscal year by your products or services? Pleaseenter the # without commas or periods. Estimates within +/- 5% are acceptable. [Not Weighted]

SE8.6 This is a calculated question based on your answer from SE8.2: Which of the following product or service descriptionsbest fit your company? 1) Products/services enable a shift in focus and resources to income-generating activities as aby-product and are designed for another purpose, OR 2) products/services whose core function is to create economicopportunity. And, question SE8.3: What % of your revenues last fiscal year were from the above products or services?[Equally Weighted]

Flow of CapitalSE9.1 Tell us more about how your product or service increases the flow of capital to purpose driven enterprises: [Not

Weighted]


Products/services are designed to *support* a purpose-driven enterprise (examples: insurance, marketing,technology or consulting services for purpose driven enterprises)

Products/services are designed to raise capital or advance the social or environmental mission of apurpose-driven enterprise (examples: fundraising for or investing in purpose-driven enterprises, sustainability oremployee engagement consulting)





SE9.5 How many of the above-selected customers were reached in the last fiscal year by your products or services? For eachcustomer type selected, please enter using numbers without commas or periods. Estimates within +/- 5% areacceptable. [Not Weighted]

SE9.6 This is a calculated question based on your answer from SE9.2: Which of the following product or service descriptionsbest fit your company? 1) Products/services are designed to *support* a purpose-driven enterprise, OR 2)Products/services are designed to raise capital or advance the social or environmental mission of a purpose-drivenenterprise. And, question SE9.3: What % of your revenues last fiscal year were from the above products or services?[Equally Weighted]

Community Business Models - Practices

Supply ChainSE13.1 Does your company's supply chain-focused model support income generation through: [Not Weighted]

Ensuring fair wages are paid to suppliers in low-income, poor or very poor markets (If Yes, Complete SE13.2 -SE13.5)

Investing and sourcing from small-scale suppliers (fewer than 50 employees) (If Yes, Complete SE13.7 -SE13.10)

Neither - If neither, skip to the next section of questions

SE13.2 Fair Wages: Which of the following statements best reflects the wage/pricing structure of a majority of your supply chain:(Check only one) [Not Weighted]

A majority (>50%) of wages/prices are unverified/unknown A majority (at least 50%) of suppliers have been verified/reviewed by your company for fair wages and labor

practices in the past 2 years A majority (at least 50%) of suppliers have had a third-party on-site verification of fair wages and labor practices in

the past 2 years A majority of suppliers (at least 50%) have a current third-party certification that ensures fair wage standards are

met None of the above (skip to SE13.7 or skip the remaining questions in this section)

SE13.3 What % of your cost of materials sourced from emerging market countries is sourced through channels that are certifiedor verified to pay fair wages? [Not Weighted]

SE13.4 What is the average premium paid to suppliers in the last year (either on product or wage)? [Not Weighted]

SE13.5 Describe in the text box the methodology your company uses to calculate producer price premium. [Not Weighted]

SE13.6 This is a calculated question based on your answer from SE13.2: Which of the following statements best reflects thewage/pricing structure of a majority of your supply chain: 1) A majority (>50%) of wages/prices are unverified/unknown,2) A majority (at least 50%) of suppliers have been verified/reviewed by your company for fair wages and labor practicesin the past 2 years, 3) A majority (at least 50%) of suppliers have had a third-party on-site verification of fair wages andlabor practices in the past 2 years, OR 4) A majority of suppliers (at least 50%) have a current third-party certificationthat ensures fair wage standards are met. And, question SE13.3: What % of your cost of materials sourced fromemerging market countries is sourced through channels that are certified or verified to pay fair wages? [EquallyWeighted]

SE13.7 Small-scale Suppliers: Which of the following statements are true about your supply chain? (Check all that apply) [NotWeighted]

Our company tracks the number of jobs that have been created through the small-scale suppliers we work with Our company provides training or technical assistance (TA) to a majority of small-scale suppliers we source from A majority of our company's input materials come from a relationship where contracts are signed and executed

for the next year with small-scale suppliers A majority of our company's input materials come from a relationship where the contract price was partially or fully

paid in advance to small-scale suppliers (including loans through a partner org) Training or TA provided by our company has resulted in quantifiable increase in productivity/efficiency of

small-scale suppliers (must be demonstrable) A majority of our company's suppliers have been fair-trade certified None - If selected, skip the remaining questions in this section

SE13.8 What % of your total Cost of Goods Sold (excluding labor costs) are sourced through small-scale suppliers (suppliers orcooperatives with supplier members that have fewer than 50 employees)? [Not Weighted]

SE13.9 What is the number of small-scale suppliers that sold to the company in the past fiscal year? [Not Weighted]

SE13.10

What is the value of payments to small-scale suppliers that sold to the company during the past fiscal year? [NotWeighted]

SE13.11

This is a calculated question based on your answer from SE13.7: Small-scale Suppliers: Which of the followingstatements are true about your supply chain? (Check all that apply) 1) Our company tracks the number of jobs that havebeen created through the small-scale suppliers we work with, 2) Our company provides training or technical assistance(TA) to a majority of small-scale suppliers we source from, 3) A majority of our company's input materials come from arelationship where contracts are signed and executed for the next year with small-scale suppliers, 4) A majority of ourcompany's input materials come from a relationship where the contract price was partially or fully paid in advance tosmall-scale suppliers (including loans through a partner org), 5) Training or TA provided by our company has resulted inquantifiable increase in productivity/efficiency of small-scale suppliers (must be demonstrable), AND/OR 6) A majority ofour company's suppliers have been fair-trade certified And, question SE13.8: What % of your total Cost of Goods Sold(excluding labor costs) are sourced through small-scale suppliers (suppliers or cooperatives with supplier members thathave fewer than 50 employees)? [Equally Weighted]

Microfranchise/Microdistribution IntroductionSE14.1 Does your company use a microfranchise (sales through the creation of branded, owner-operated micro-businesses

(fewer than 10 employees) to sell product) or microdistribution (sales through a distribution network of independent salesrepresentatives/agents) model? (Check only one) Based on your response to question 14.1, you should complete eitherthe Microfranchise section (SE15) or the Microdistribution section (SE16). [Not Weighted]

Microfranchise - My company uses a microfranchise model to distribute its products/services (If Yes, CompleteSE15.1 - SE15.5 below)

Microdistribution - My company uses a microdistribution model to distribute its products/services (If Yes,Complete SE16.1 - SE16.4 below)

MicrofranchiseSE15.1 Does your microfranchise model include the following: [Not Weighted]

On-going product and operations training provided for all franchisees Training goes beyond basic operational/financial skills needed to operate the franchise At least 50% of franchisees are located in rural or urban poor areas Cost-sharing or inventory structure of branded product offerings Franchisees are micro- or small-businesses (fewer than 50 employees) Franchisees are low income, poor or very poor The franchisee must have at least 50% ownership stake in their business

SE15.2 Did you select at least 5 of the 7 above statements? [Not Weighted]

No (less than 5 statements selected) - Skip the remaining questions in this section Yes, 5 or more statements selected (If Yes, Complete SE15.3 - SE15.5)

SE15.3 What % of total business is generated through microfranchising? [Equally Weighted]

0% 1 - 15% 16 - 30% 31- 50% 51% +

SE15.4 Are pricing / financial agreements intended to lift microfranchises out of poverty through any of the following approaches:[Not Weighted]

Cost-sharing for start-up expenses or inventory Royalties/pricing for all products for all microfranchises <4% of sales or <15% of franchisee margin (user the

higher of two numbers) Royalties/pricing for all products for all microfranchises <6% of sales or <30% of franchisee margin (use the

higher of two numbers)

SE15.5 What is your microfranchisee retention rate (excluding those franchises that have left because the outcome has beenachieved)? An example of an achieved, intentional outcome may include a microfranchisee moving onto open a fullscale business of his/her own where the revenue stream offered through your company is no longer needed. [NotWeighted]

Don't Know <75% 75-85% 85-95% 95+%

MicrodistributionSE16.1 Does your microdistribution model include the following: [Not Weighted]

Microdistributors are small and independently-owned businesses (fewer than 50 workers) or smaller (includingsole proprietors)

Microdistributors are low income, poor or very poor Income from distribution of your company's product or service comprises at least half (50%) of microdistributors'

total business income Microdistributors receive training in order to effectively sell product/service

SE16.2 Did you select 3 of the 4 statements above? [Not Weighted]

No (less than 3 statements selected) - If no, skip the remaining questions in this section. Yes, 3 or more statements selected (If Yes, Complete SE16.3 - SE16.4)

SE16.3 What % of total business is generated through microdistribution? [Equally Weighted]

0 1 - 15% 16 - 30% 31 - 50% 51%+

SE16.4 What is your microdistributor retention rate (excluding those franchises that have left because the outcome has beenachieved)? An example of an achieved, intentional outcome may include a microfranchisee moving onto open a fullscale business of his/her own where the revenue stream offered through your company is no longer needed. [NotWeighted]

Don't Know <75% 75-85% 85-95% 95+%

Producer CooperativeSE17.1 Is your company a registered producer cooperative whose owners are small business supplier members that organize

production? (each supplier member has fewer than 50 employees) [Not Weighted]

Yes

No - Ifno, skiptheremainingquestionsin thissection

SE17.2 If yes, what % of members are from low income, poor and very poor populations? [Equally Weighted]

SE17.3 If yes, what % of Cost of Goods Sold (excluding labor costs) was purchased from co-op members in the last fiscal year?[Equally Weighted]

Charitable GivingSE18.1 Does the company have a written requirement to give greater than 20% of its profits to charitable partners (including pro

bono or in-kind donations) or does it have an associated non-profit/foundation? If the company is not profitable, does ithave a requirement to give at least 5% of revenues to charitable partners? [Not Weighted]

Yes

No - Ifno, skiptheremainingquestionsin thissection

SE18.2 If yes, what % of profits or sales does the company donate to charity (including in-kind donations)? If the company isprofitable, use profit to calculate %. If the company is not yet profitable, use sales to calculate %. [Equally Weighted]

0-19% profits/0-4% sales 20-29% profits/5-7.4% sales 30-39% profits/7.5-9.9% sales 40-49% profits/10-12.4% sales 50+% profits/12.5+% revenues My company established a non-profit/foundation that is associated with the business through on-going activities to

which we are mandated to provide a majority of funding and we donate at least 10% of profits (or 2% of sales)annually.

Local Economic DevelopmentSE19.1 Is your company a nationally registered independent company (not a franchise or subsidiary) in your country? [Not

Weighted]

Yes (IfYes,CompleteSE19.2 -SE19.3)

No (IfNo, skiptheremainingquestionsin thissection)

SE19.2 Which of the following was your company designed to contribute to the national economic development in its country ofoperations? [Not Weighted]

Import substitution: Prior to company's entry into the local market, over 80% of the product it manufactures ordelivers was only available via import or from foreign companies

Privatization: Company privatized manufacturing or service delivery of its core products/services within last 5years (transitioned from government operations)

None of the above - If None, skip the remaining questions in this section and proceed to the next page.

SE19.3 Which of the following does your company contribute to national economic development in its country of operations?Check all that apply: [Equally Weighted]

Local supply chain development: Company sources 80% of its input materials from or 80% of cost of goods sold(including value-add activities) is spent within country of operations, from independent in-country registeredcompanies or national citizens

Private sector support: Company has founded new industry or trade association to encourage national industrygrowth and partnership

Local management: At least 80% of managers are national citizens of country of operations Local ownership: Majority of company ownership is held by national citizens of country of operations None of the above

Environmental Business Models - Practices

Wholesale: EnvironmentSE27w.1

Which of the following statements are true about your environmental wholesale practices? (Check all that apply) [NotWeighted]

Stated objectives and targets exist for environmental aspects of your company operations Offices and facilities have been fitted to maximum energy efficiency (including windows, roofing, lighting, building

materials, furniture and equipment). 50%+ of input materials used are organic, sustainably-sourced, or from recycled materials All energy and water usage is monitored Significant suppliers are screened for their social and environmental practices and impacts Significant suppliers are required to report on their social and environmental practices on an annual basis

SE27w.2

How many above the above statements are true about your environmental wholesale practices? [Equally Weighted]

3 out of 6 or less 4 out of 6 5 out of 6 6 out of 6

Environmental Business Model - Products & Services Introduction

Environment P&S IntroductionSE 20.1 How does your product or service conserve the environment? (Please select the ONE most impactful way that each

product line is solving an environmental problem.)

Yes No

Provides or is powered by renewable energy or cleaner-burning energy than market alternatives

Yes No

Conserves resources (energy &/or water efficient)

Yes No

Reduces waste (provides recycling technology/service or uses recycled input materials)

Yes No

Land or wildlife conservation (i.e. sustainable harvest, land protection or reforestation)

Yes No

Toxic/hazardous substance reduction, pollution prevention and remediation (i.e. organic food, pesticidealternatives, non-toxic cleaners, brownfield remediation)

Yes No

Educates, measures, researches, or provides information to solve environmental problems (i.e.environmental consulting or auditing)

SE20.2 Does your product or service have any third-party certifications? If so, please list certifications. To meet the GIIRSdefinition of a qualified third-party certification, the certification must be from a third party, be standards-based, and havethose standards be transparent. [Not Weighted]

Environmental Business Models - Products & Services

Renewable or cleaner-burning energySE21.1 Tell us more about how your product or service provides or is powered by renewable energy or cleaner-burning energy

than market alternatives. [Not Weighted]

SE21.2 Which of the following product or service descriptions apply? [Not Weighted]

Product or service is powered by fossil fuel-based energy that is cleaner-burning than market alternatives anddesigned for another purpose (Examples: LPG-powered car, natural gas burning heater)

Product or service provides fossil fuel-based energy that is cleaner-burning than market alternatives (Examples:LPG distribution, natural gas distribution)

Product or service is self-powered by renewable energy (non-fossil fuel) and is used for another purpose(Example: solar light, hand-powered radio, wind-powered water heater, etc.)

Product or service provides or contributes to provision of renewable energy (non-fossil fuel) to households,businesses or communities (Example: solar panel installation, solar panel manufacturing, wind turbinemanufacturing)


SE21.3 Which of the following renewable energy types are provided by product/service? [Not Weighted]

Solar Wind Biodiesel/biomass (please specify type) Small-scale hydro Other

SE21.4 Has the company's renewable energy products/services received a third-party verification or certification for carbonoffsets? [Not Weighted]

Certified emission reduction credits (verified and registered by United Nations) Verified emission reductions credits ("unofficial" carbon credits, not allocated by the UN) Renewable energy credits or local equivalent (third-party verified units of renewable energy) None of the above

SE21.5 How many kilowatt hours (kWh) were generated in the last fiscal year by your products or services? [Not Weighted]

SE21.6 How many metric tonnes of CO2 equivalent were saved/offset in the last fiscal year by your products or services? [NotWeighted]


SE21.8 This is a calculated question based on your answer from SE21.2: Which of the following product or service descriptionsapply? 1) Product or service is powered by fossil fuel-based energy that is cleaner-burning than market alternatives anddesigned for another purpose, 2) Product or service provides fossil fuel-based energy that is cleaner-burning thanmarket alternatives, 3) Product or service is self-powered by renewable energy (non-fossil fuel) and is used for anotherpurpose, OR 4) Product or service provides or contributes to provision of renewable energy. And, question SE21.7:What % of your revenues last fiscal year were related to the above products or services? [Equally Weighted]

Energy & water efficiencySE22.1 Tell us more about how your product or service reduces energy and/or water use. [Not Weighted]


Product or services uses less energy &/or water than market alternatives but is designed for another purpose(Examples: EnergyStar (energy-efficient) appliances, low-flow shower heads & toilets, automatic thermostats, etc.)

Product or services is designed to conserve energy &/or water use (Examples: Energy or water useassessment/consulting services or software, grey water (water recycling) systems)


SE22.3 What is the average % energy reduction achieved by the product or service? [Not Weighted]

SE22.4 What is the average % water reduction achieved by the product or service? [Not Weighted]


SE22.6 How many metric tonnes of CO2 equivalent were saved in the last fiscal year by your energy-efficient products orservices? [Not Weighted]

SE22.7 How many liters of water were saved/conserved in the last fiscal year by your water efficient products or services? [NotWeighted]

SE22.8 This is a calculated question based on your answer from SE22.2: Which of the following product or service descriptionsapply? Product or services uses less energy &/or water than market alternatives but is designed for another purpose, orProduct or services is designed to conserve energy &/or water use. And, question SE22.5: What % of your revenues lastfiscal year were related to the above products or services? [Equally Weighted]

Waste ReductionSE23.1 Tell us more about how your product or service reduces waste output. [Not Weighted]


Product or services uses recycled input materials but is designed for another purpose (Examples: products madewith recycled input materials (recycled paper, recycled glass surfaces) or refurbished items (furniture, equipment))

Product or service is designed to reduce overall waste sent to landfill or incinerated (Examples: residentialrecycling programs/services, recycling technologies, composting services)


SE23.3 What is the % of recycled input materials (by weight or volume) in product or offered through service? [Not Weighted]

SE23.4 What is the average % waste reduction achieved by the product or service? [Not Weighted]


SE23.6 How many metric tons of waste were saved from landfill or incineration in the last fiscal year by your products orservices? [Not Weighted]

SE23.7 This is a calculated question based on your answer from SE23.2: Which of the following product or service descriptionsapply? 1) Product or services uses recycled input materials but is designed for another purpose, OR 2) Product orservice is designed to reduce overall waste sent to landfill or incinerated. And, question SE23.5: What % of yourrevenues last fiscal year were related to the above products or services? [Equally Weighted]

Land or wildlife conservationSE24.1 Tell us more about how your product or service conserves natural resources [Not Weighted]


Product or services uses sustainable harvest of natural resources or input materials but is designed for anotherpurpose (Examples: FSC certified wood/paper, MSC seafood, sustainably harvested brazil nuts, shade-growncoffee, etc.)

Product or service is designed to preserve natural environments and wildlife through directconservation/protection from external degradation (Examples: protected parks, land & wildlife conservation, etc.)

Product or service is designed to improve natural environments through reforestation or natural wildliferepopulation (Examples: planting trees, efforts to repopulate endangered species, etc.)



SE24.4 What is the unit of mesurement for the key metric tracked to measure impact? (i.e. # of hectares protected, # of wildlifesaved, etc.) [Not Weighted]

SE24.5 How many above "units" were conserved/improved in the last fiscal year by your products or services? [Not Weighted]

SE24.6 This is a calculated question based on your answer from SE24.2: Which of the following product or service descriptionsapply? 1) Product or services uses sustainable harvest of natural resources or input materials but is designed foranother purpose, 2) Product or service is designed to preserve natural environments and wildlife through directconservation/protection from external degradation, OR 3) Product or service is designed to improve naturalenvironments through reforestation or natural wildlife repopulation. And, question SE24.3: What % of your revenues lastfiscal year were related to the above products or services? [Equally Weighted]

Toxic/hazardous substance reduction, pollution prevention and remediationSE25.1 Tell us more about how your product or service reduces use of toxic or hazardous substances, prevents pollution or

remediates discharges to air, land or water [Not Weighted]


Product or services uses less toxic/hazardous chemicals or materials than market alternatives but is designed foranother purpose (Examples: non-toxic cleaners or chemical products, organic food, integrated pest management foragriculture)

Product or service is designed to prevent pollution or hazardous discharge (Examples: manufacturing pollutioncontrol mechanisms)

Product or service is designed to remediate environmental damage after discharges to air, land or water(Examples: brownfield remediation, oil spill clean-up services)


SE25.3 What is the average % toxic/hazardous material reduction or pollution prevention (by weight or volume) achieved by theproduct or service? [Not Weighted]


SE25.5 What is the unit of mesurement for the key metric tracked to measure impact? (i.e. liters, units sold, metric tonnes ofCO2 equivalent, etc) [Not Weighted]

SE25.6 How many above "units" were replaced/saved/remediated in the last fiscal year by your energy efficient products orservices? [Not Weighted]

SE25.7 This is a calculated question based on your answer from SE25.2: Which of the following product or service descriptionsapply? 1) Product or services uses less toxic/hazardous chemicals or materials than market alternatives but is designedfor another purpose, 2) Product or service is designed to prevent pollution or hazardous discharge, OR 3) Product orservice is designed to remediate environmental damage after discharges to air, land or water. And, question SE25.4:What % of your revenues last fiscal year were related to the above products or services? [Equally Weighted]

Education, measurement and consultingSE26.1 Tell us more about how your product or service educates, quantifies, or provides strategic advise to solve environmental

problems [Not Weighted]


Educates or provides information on efficient resource use or environmentally-friendly alternatives for consumersand businesses (Examples: carbon credit trading platforms, environmental resource guides)

Conducts environmental science research and publishes results/reports to the general public (Examples:environmental research laboratory)

Other These descriptions do not apply to our company's product/service (Skip the remainder of this section)


SE26.4 Unit of Impact [Not Weighted]

Individuals Households Businesses Unique Readers

SE26.5 How many of the above units were served in the last fiscal year by your products or services? [Not Weighted]

SE26.6 This is a calculated question based on your answer from SE26.2: Which of the following product or service descriptionsapply? 1) Educates or provides information on efficient resource use or environmentally-friendly alternatives forconsumers and businesses, 2) Conducts environmental science research and publishes results/reports to the generalpublic, OR 3) Other. And, question SE25.3: What % of your revenues last fiscal year were related to the above productsor services? [Equally Weighted]

Disclosure Questionnaire

Disclosure Questionnaire

IndustriesDQ1.1 Please indicate if the company is involved in production of or trade in any the following (check all that apply.)

Yes No

Any product or activity deemed illegal under host country laws or regulations or international conventionsand agreements

Yes No

Alcohol (excluding beer and wine)

Yes No

Commercial logging and logging equipment

Yes No

Firearms, weapons or munitions

Yes No

Genetically modified organisms

Yes No

Mining

Yes No

Pharmaceuticals subject to international phase-outs or bans

Yes No

Payday lending

Yes No

Pornography

Yes No

Tobacco

Yes No

Wildlife or wildlife products regulated under the Convention on International Trade in Endangered Speciesof Wild Fauna and Flora (CITES)

DQ1.2 If you selected "Yes" above, please provide a detailed explanation of the company's involvement here. []

PracticesDQ2.1 Please indicate if the following statements are true regarding whether or not the company engages in the following

practices (check all that apply.) If the statement is true, select "True." If false, select "False."

True False

Company formally registered in accordance with domestic regulations

True False

Company facilities are not located adjacent to or in sensitive ecosystems

True False

Company provides clean drinking water to employees at all times

True False

Company workers, company contractors, company subcontractors or day-workers are paid minimumwage or above

True False

Company keeps a signed contract of employment with each worker

True False

Company or company supplier does not employ workers under the age of 15 (or other minimum workage covered by the International Labour Organization Convention No. 138 ) and company keepspersonnel records that include evidence of the date of birth of each

True False

Overtime work for hourly workers is voluntary (not compulsory)

True False

Company provides payslips or equivalent to all workers to clearly show how wages are calculated andany deductions made

True False

Company or company suppliers do not use any workers who are prisoners

True False

Company allows workers to freely associate and to bargain collectively for the terms of one’semployment

True False

Company allows workers to freely leave the site during non-working hours or at the end of their shift(including workers who live on site)

True False

Company does not keep workers' original Id Cards/Passports

DQ2.2 If you selected "False" above, please provide a detailed explanation of the company's engagement in these practiceshere. []

OutcomesDQ3.1 Please indicate if the following statements are true regarding if the company has experienced any of the following in the

past 5 years (check all that apply.) If the statement is true, select "True." If false, select "False."

True False

Company has not had an operational or on-the-job fatality

True False

Company site has not experienced any accidental discharges to air, land or water of hazardoussubstances

True False

No construction nor operation of company facility has resulted in the relocation of any individuals orhouseholds near your facility

True False

No material litigation against company

DQ3.2 If you selected "False" above, please provide a detailed explanation of the company's experience related to the abovestatement here. []

PenaltiesDQ4.1 Please indicate if the company has had any formal complaint to a regulatory agency or been assessed any fine or

sanction in the past five years for any of the following practices or policies (check all that apply.)

Yes No

Animal welfare

Yes No

Diversity and equal opportunity

Yes No

Employee safety or workplace conditions

Yes No

Environmental issues

Yes No

Financial reporting

Yes No

Geographic operations or international affairs

Yes No

Labor issues (internal and supply chain)

Yes No

Marketing

Yes No

Political contributions

Yes No

Taxes

DQ4.2 If you selected "Yes" above, please provide a detailed explanation of the complaint/fine/sanction here. []

version: wholesale/retail track, 0 employees, emerging marketcm6.2 what % of profits or sales was...

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