Pacific Islands HIV and STI Response Fund Grant Proposal Form
PACIFIC ISLANDS HIV AND STI RESPONSE FUND
FUNDING STREAM V
PRSIP SUPPORT
PROPOSAL
1. General project information
1.1
Project title, location and timing
Project name:
Country/region/province/specific location(s):
Project timing:
1.2
Expected start date
Expected finish date
Project duration
Agency details
Primary implementing agency:
Name
Principal contact officer
Telephone number
Fax number
Email address
Partner organisations (if any):
1.3
Request to funding stream V – PRSIP Support Grants
Total funds requested:
2. What specific PRSIP theme will this project address?
Please tick one or more boxes
Prevention programmes
□ HIV and other STI diagnosis
Leadership and enabling environment
□ Strategic information and communication
Continuum of CT&S (Care Treatment & Support) systems and services
Governance and coordination
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Pacific Islands HIV and STI Response Fund Grant Proposal Form
3. Needs analysis and project design
3.1
What are the needs/issues to be addressed?
3.2
What agencies, programs, projects and activities are already addressing the needs
identified in 2?
3.3
How will your project address these needs/issues?
3.4
How did you develop this response (e.g., who did you consult)?
3.5
What is the goal of your project?
3.6
What priority area(s) in PRSIP II plan does your project address?
3.7
Summary log frame
Project summary
Performance indicators
significant change
domains
Means & sources of
verification
Risks & important
assumptions
Project outcome
Major project outputs
Major project inputs
3.8
Who are the direct & indirect beneficiaries of this project?
4. Project cross-cutting issues
4.1
How will you ensure that your project benefits both men and women?
4.2
Will you target identified vulnerable groups? If so how?
4.3
How will you ensure sustainability of project activities?
4.4
What are the key project risks and how will you manage these?
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Pacific Islands HIV and STI Response Fund Grant Proposal Form
5. Project management and coordination
5.1
Who will be involved in project implementation and coordination?
5.2
Monitoring and reporting
Logframe
ref.
5.3
Indicator
Data
collectors
Frequency of
data collection
Frequency of
reporting
Report writer
What other HIV and STIs programs exist in the area your proposal is addressing?
6. Budget
Costs to be in local currency
Project budget
Year 1 Year 2 Year 3 Total
1. Activity personnel
Name/position/function/time dedicated to activity
Staff costs
2. Non-personnel inputs
Communication costs
Other operating costs (e.g., freight and insurance inputs)
Capital costs
3. In-country activity support costs
HIV & STI related consumables (e.g., drugs, condoms, test kits)
Transport & travel costs
Conference, training and workshop costs
Fieldwork
Study & research costs
Publications & production materials
Subtotal
Evaluation costs (to a maximum of 5% total funding)
Total
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Pacific Islands HIV and STI Response Fund Grant Proposal Form
7. Declaration
The following undertaking must be made by an appropriately authorised officer of the
organisation receiving funding through this project.
I, (authorised officer) ...............................................................................................................................
(position held) ...........................................................................................................................................
submit this proposal and undertake that all funds provided will be expended for the purposes for
which they are provided.
Signature ............................................................................
Date ...................................................................................
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