SayPro Ethical Disclosure & Impact Assessment Form

Document ID: SPEDIAF-2025-001
Date of Submission: [DD/MM/YYYY]
Prepared By: [Full Name / Organization Name]
Role in Program: [Project Lead / Partner / Volunteer / Consultant / Other]

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📄 Section 1: Program & Activity Overview

Field	Details
Program Name	[SayPro Initiative Title]
Program Code	[SayPro-PRG-2025-XXX]
Project Location	[City / Region / Country]
Duration of Activity	[Start Date – End Date]
Main Objectives	[Brief summary of purpose and goals]

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🤝 Section 2: Ethical Disclosure

Ethical Area	Disclosure (Yes/No)	If Yes, Provide Details
Conflict of Interest Present
Personal/Organizational Benefit
Use of Sensitive/Confidential Data
Data Collection from Vulnerable Groups
Use of Partner Logos/Materials
Prior Ethical Clearance Obtained		[Attach proof if applicable]
Risk of Harm (direct/indirect)

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🌍 Section 3: Impact Assessment (Social, Economic, Environmental)

Impact Category	Positive Impact (✓)	Negative Impact (✓)	Description / Mitigation Plan
Community Empowerment
Gender Equity
Youth Inclusion
Environmental Practices
Local Economic Benefits
Digital/Data Ethics
Cultural Sensitivity

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🧾 Section 4: Documentation & Evidence

Required Documents	Submitted (✓/✗)	Notes
Risk Assessment Report
Consent Forms (if human subjects involved)
Ethical Clearance Letter
Stakeholder Engagement Records
Environmental Impact Summary (if applicable)

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📝 Section 5: Declaration

I, the undersigned, confirm that the information provided above is accurate and complete to the best of my knowledge. I agree to comply with SayPro’s ethical standards, policies on transparency, and commit to responsible program implementation.

Name: _______________________
Signature: __________________
Date: _______________________
Organization (if applicable): ______________________________

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🖊️ Section 6: SayPro Review & Feedback (Internal Use Only)

Reviewer Name	Title	Review Notes	Final Decision
			Approved / Rework / Rejected