(Sheet 2-1.

APPLICATION FORM FOR JAPAN’S TECHNICAL COOPERATION

1. Date of Entry: Day Month Year

2. Applicant:

3. Technical Cooperation (T/C) Title:

4. Type of the T/C

☒Science and Technology Research Partnership for Sustainable
Development（SATREPS）

5. Contact Point (Implementing Agency):

Address:
Contact Person:
Tel. No.: +
E-Mail:

6. Background of the T/C

（ Current conditions of the sector, Government’s development policy for the
sector, Issues and problems to be solved, Existing development activities in the
sector, the Project’s priority in the National Development Plan / Public
Investment Program, etc.）
(Please tick in check box if any items below apply the T/C)(for African Countries
or Latin America and the Caribbean Countries only)
□ Contents of the T/C match with the National Development Plan
□ Contents of the T/C match with STI for SDGs Roadmap

7. Outline of the T/C

(1) Overall Goal
(Long-term objective)

(2) T/C Purpose

(Objective expected to be achieved by the end of the project period.
Elaborate with quantitative indicators if possible)
(3) Outputs
(Objectives to be realized by the “T/C Activities” in order to achieve the “T/C
Purpose”)

(4) T/C Site

（In case there is any particular candidate site, please give specifics such as
the name of the target area for the T/C and attach a rough map to the
documents submitted. The attached map should be at a scale that clearly
shows the project site.）

(5) T/C Activities

(Specific actions intended to produce each “Output” of T/C by effective use
of the “Input”. )

(6) Input from the Recipient Government

(Counterpart personnel (identify the name and position of the Project
manager), support staff, office space, running expenses, vehicles,
equipment, etc.)

(7) Input from the Japanese Government

(Number and qualification of Japanese experts/consultants, contents of
training (in Japan and in-country) courses, seminars and workshops,
equipment, etc.)

8. Implementation Schedule

Month Year 〜 Month Year

9. Description of an Implementing Agency

(Budget allocated to the Agency, Number of Staff of the Agency,

Department/division in charge of the T/C, etc.)
10. Activities in the same sector of other donor agencies, the recipient
government and NGOs and others:
(Please pay particular attention to the following items:
−Whether you have requested the same project to other donors or not.
−Whether any other donor has already started a similar project in the
target area or not.
−Presence/absence of cooperation results or plans by third-countries or
international agencies for similar projects.
−In the case that a project was conducted in the same field in the past,
describe the grounds for requesting this project/study, the present status
of the previous project, and the situation regarding the technology transfer.
−Whether there are existing projects/studies regarding this requested
project/ study or not. (Enter the time/period, content and concerned
agencies of the existing studies.))

11. Global Issues

(Any relevant information of the project from global issues (gender, poverty,
climate change, etc.) perspective.)
(1) Gender
(2) Poverty
(3) Climate change
(4) Others

12. Environmental and Social Considerations

(In case of Technical Cooperation Project（including SATREPS） / Technical

Cooperation for Development Planning, please fill in the attached screening
format.)
(Note) If JICA considers that the environmental and social considerations are
required to the T/C, the applicants agree on JICA’s information disclosure of
the T/C for public hearing in accordance with JICA guidelines for
environmental and social considerations as stated in Question 11 of the
attached Screening Format.
13. Others

Signed:
Title:
On behalf of the Government of
Date:
Additional Form for SATREPS

1. Japanese Partner of SATREPS

(1)Research Institutions：
(2)Principal Investigator of Japanese side：
(3)Other Researchers：

2. Institutional profile
(1)Research Institutions：
(2)Principal Investigator：
(3)Previous international joint research projects related this SATREPS (Give their
titles in English) If the projects are supported by other agencies, provide agency
names, and years.
(4)Current research projects related this SATREPS (Give their titles in English) If the
projects are supported by other agencies, provide agency names, and years)

3. List of available equipment for the proposed research

Screening Format（Environmental and Social Considerations）

Name of Proposed Project:

Project Executing Organization, Project Proponent or Investment Company:
Name, Address, Organization, and Contact Point of a Responsible Officer:

Name:
Address:
Organization:
Tel:
E-Mail:
Date:
Signature:
Check Items
Please write “to be advised (TBA)” when the details of a project are yet to be
determined.

Question 1: Address of project site

Question 2: Scale and contents of the project (approximate area, facilities area,
production, electricity generated, etc.)
2-1. Project profile (scale and contents)
2-2. How was the necessity of the project confirmed?
Is the project consistent with the higher program/policy?
☐ YES: Please describe the higher program/policy.
( )
☐ NO
2-3. Did the proponent consider alternatives before this request?
☐ YES: Please describe outline of the alternatives
( )
☐ NO

2-4. Did the proponent implement meetings with the related stakeholders before this
request?
☐ Implemented ☐ Not implemented
 If implemented, please mark the following stakeholders.
☐ Administrative body
☐ Local residents
☐ NGO
☐ Others

(1) ☐ The local residents above include socially vulnerable individuals/groups

(Please specify: )
(2) ☐ The proponent gave appropriate consideration to ensure participation of the
socially vulnerable individuals/groups

Question 3:
Is the project a new one or an ongoing one? In the case of an ongoing project, have
you received strong complaints or other comments from local residents?
☐ New ☐ Ongoing (with complaints) ☐ Ongoing (without complaints)
☐ Other ( )

Question 4:
Is an Environmental Impact Assessment (EIA), including an Initial Environmental
Examination (IEE) required for the project according to a law or guidelines of a host
country? If yes, is an EIA implemented or planned? If necessary, please fill in the
reason why an EIA is required.
☐ Necessary (☐ Implemented / ☐ Ongoing/planning)
(Reason why EIA is required: )
☐ Not necessary
☐ Other (please explain: )

Question 5:
In the case that steps were taken for an EIA, was the EIA approved by the relevant
laws of the host country? If yes, please note the date of approval and the competent
authority.
☐ Approved without a supplementary condition (Date of approval: Competent
authority: )
☐ Approved with a supplementary condition (Date of approval: Competent authority:
)
☐ Under appraisal
☐ Under implementation
☐ Appraisal process not yet started
☐ Other ( )

Question 6:
If the project requires a certificate regarding the environment and society other than an
EIA, please indicate the title of said certificate. Was it approved?
☐ Already certified
Title of the certificate: ( )
☐ Requires a certificate but not yet approved
☐ Not required
☐ Others ( )

Question 7:
Are any of the following areas present either inside or surrounding the project site?
☐ Yes ☐ No
If yes, please mark the corresponding items.
☐ National parks, nationally-designated protected areas (coastal areas, wetlands,
areas for ethnic minorities or indigenous peoples and cultural heritage, etc. designated
by national governments)
☐ Primary forests, natural forests in tropical areas
☐ Habitats with important ecological value (coral reefs, mangrove wetlands, tidal flats,
etc.)
☐ Habitats of rare species that require protection under domestic legislation,
international treaties, etc.
☐ Areas in danger of large-scale salt accumulation or soil erosion
☐ Areas with a remarkable tendency of desertification
☐ Areas with unique archeological, historical, or cultural values
☐ Areas inhabited by ethnic minorities, indigenous peoples, or nomadic peoples with
traditional ways of life, and other areas with special social values

Question 8:
Does the project include any of the following items?
☐ Yes ☐ No
If yes, please mark the appropriate items.
☐ Involuntary resettlement (scale: households, persons)
☐ Groundwater pumping (scale: m3/year)
☐ Land reclamation, land development, and/or land-clearing (scale: hectors)
☐ Logging (scale: hectors)

Question 9:
Please mark related environmental and social impacts, and describe their outlines.
☐ Air pollution ☐ Involuntary resettlement
☐ Water pollution ☐ Local economies, such as

☐ Soil pollution employment, livelihood, etc.

☐ Waste ☐ Land use and utilization of

☐ Noise and vibration local resources

☐ Ground subsidence ☐ Social institutions such as social

☐ Offensive odor infrastructure and local decision-making

institutions
☐ Geographical features
☐ Bottom sediment ☐ Existing social

☐Biodiversity and ecosystems infrastructures and services

☐Water usage ☐ Socially vulnerable people

☐Accidents (Indigenous people, ethnic minorities)
☐Climate change ☐ Socially vulnerable people (People
in poverty, persons with disabilities,
refugees, internally displaced persons,
and minorities)
☐ Misdistribution of benefits and
damages
☐ Local conflicts of interest
☐ Limitation of accessibility to
information, meetings, etc. on a specific
person or group
☐ Gender
 ☐ Children’s rights

☐ Cultural heritage
☐ Infectious diseases such as
HIV/AIDS

☐ Others ( )

Outline of related impact:

( )

Question 10:
In the case of a project such as a two-step loan or a sector loan, can sub-projects be
specified at the present time?
☐ Yes ☐ No

Question 11:
Regarding information disclosure and meetings with stakeholders, if JICA’s
environmental and social considerations are required, does the proponent agree to
information disclosure and meetings with stakeholders through these guidelines?
☐ Yes ☐ No