2012 Capacity-Building Intervention Plan
CAPACITY-BUILDING PLAN FORM
Changes have been made to the form, please use this year’s form; do not update a previous year’s form.
Please be brief, but informative.
Updated Instructions This form should be used to record plans for (1) the delivery of capacity building with
community based agencies, volunteer networks, clinical service providers and other organizations serving
populations at risk for HIV; and (2) desired outcomes of service delivery or institutional changes targeting HIV risk
populations that will be implemented by agencies and organizations as a result of capacity building activities.
1. AGENCY, FUNDING AND INTERVENTION INFORMATION
Complete this column 
Agency information
Agency Name
Address line 1
Address line 2
City, State, Zip Code
Contact person for this intervention plan
Name
Phone
Email
Funding amount for this intervention plan
From all sources
From AIDS/HIV Program
Full-time equivalent (FTE) employees for this
intervention plan
From all sources
From AIDS/HIV Program
About the intervention
Intervention plan name
Intervention type
Capacity Building
2. HIV Risk(s) of Client Population served by agencies receiving Capacity Building
services
Identify the population(s) reached by the service provider(s) to whom you will provide capacity-building
For example, if you will provide trainings, workshops, and/or 1:1 agency consultation to organizations
serving gay youth, the client population would be "MSM".
Select all that apply—replace with X
 MSM
 IDU
 HIV-Positive persons
 High-Risk Heterosexual Females
 General Population / Other (please describe):
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2012 Capacity-Building Intervention Plan
3. STRATEGIES TO PROVIDE CAPACITY BUILDING
(activities your agency will deliver to CBOs, agencies & other providers)
Strategy
Number
of events
Unduplicated
number of
Agencies or
Groups
Unduplicated
number of
staff or
gatekeepers
working with
the target
population
Other:
specify
Other:
specify
Conference
Training sessions/workshops
One-time community events/meeting
Ongoing advisory group/task force
Consultation – one-on-one
Mini-grantee
-----
Other: specify
Goal
4a. AGENCY-LEVEL OUTCOMES
(activities agencies will do as a result of participating in Capacity Building)
Total
Total unduplicated number of agencies or groups reached by your capacity-building
activities (from section 3 above).
Among the total unduplicated # of agencies, estimate the following based on capacity-building
activities you will provide…
# of agencies that will participate in events targeting high-risk populations (MSM, IDU, etc.)
# of agencies that will participate in community HIV events to reduce stigma and normalize
HIV testing (National testing days, Black Church Week of Prayer, etc.)
# of agencies that will make institutional changes, (conducting needs assessments,
identifying services gaps, implementing staff training programs on HIV services, etc.)
# agencies that will initiate new HIV services or programs and/or expand existing HIV
services or programs, particularly for at-risk or disproportionately-affected populations
# of agencies that will receive additional funding for HIV services or programs
other:
4b. CLIENT-LEVEL OUTCOMES
(services clients will receive from agencies as a result of Capacity Building activities).
Strategies
Population
Service delivery model,
frequency and setting
Content/Skills
Conference
One-time community event
Ongoing advisory group/task force
Training sessions/workshops
HIV CTR Services
HIV Prevention EBIs
Condom Distribution
Other:
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2012 Capacity-Building Intervention Plan
5. WORK PLAN TIMELINE
Key dates
Needs assessment
Program/venue development:
Hiring/training:
Services begin:
Other:
6. STAFFING AND DATA COLLECTION PLAN
Intervention Supervisor
Name, title, phone and e-mail
Supervision Plan
Describe briefly
Direct Staff:
For each staff member working on this intervention,
name, position, appropriateness for the intervention
and population
Data Entry/ Reporting Contact
Name, title, phone and e-mail
Data Entry/Reporting Plan
Describe briefly
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2012 Capacity-Building Intervention Plan
7. BUDGET NARRATIVE
Describe costs associated with this intervention plan in each of the categories below.
Line Item
Name or item
Description and quantity
$
Personnel
Consultant/
Contractual
Supplies &
Equipment
Operations
Total Direct
Costs
Indirect
Costs (not
more than 10%
of direct costs)
Total Costs
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