Jobs M&E Data Collection Form - Individual Beneficiaries

Section 1 - Screening information

This data is collected to assess the performance of [INSERT PROJECT NAME] supported by the World Bank Group.

[PROVIDE ADDITIONAL TEXT REGARDING THE SPECIFIC INTERVENTION AND RATIONALE FOR COLLECTING THIS DATA - I.E. TO MEASURE AND REPORT PROGRESS ON PROJECT RESULTS].

The information gathered is strictly confidential and will only be used in aggregated form; data will never be identifiable in any report or data set. The information gathered here is exclusively meant to help improve existing and develop new programs to better support [INSERT BENEFICIARIES TYPE].

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* First name w 0

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* Last name w 0

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* Address w 0

Street name

Street number

City

Country

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* Phone number (please indicate at least 3 phone numbers: your number(s) as well as two more of family members or friends) w 0

Phone number I

Phone number II

Phone number III

Phone number IV

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* Gender w 0

Male

Female

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* Year of birth w 0

5% of survey complete.