BACKUP Health – Application Form – Project Mode
Please note: The contracting partner must be registered as a legal entity. A completed self-disclosure form
must be attached to your application together with the required documents/certificates. If not, the application
will not be further processed.
Download: Self-disclosure for the commercial suitability review (docx, 96 KB)
Name of applicant:
Institution/organisation:
Address:
Phone:
Email:
Are you a:
CCM
Principal Recipient
Health sector body
Other
If you are a CCM and not registered as a legal entity, please indicate a CCM member organisation
registered as a legal entity as a contracting partner for the proposed project:
CCM member organisation:
Name:
Address:
Phone:
Email:
If you are a Global Fund Principal Recipient, please detail which grant(s) you have received.
Grant reference number
Disease component
(HIV, TB, malaria)
Which constituency do you represent?
academic/training institution
international civil society organisation
national civil society organisation
multilateral organisation
HSS/
strengthening civil
society
Most recent grant
performance rating
national government institution
private sector organisation
regional initiative
Country or region covered:
Time frame of the intervention:
Start: (Please enter specific date
or month)
End: (Please enter specific date or
month)
Period: (Please enter number of
days or months)
Intervention area (Please tick one of the three headings below.):
Country Coordinating Mechanism (CCM)
Health System Strengthening (HSS)
Grant Management (GM)
Have you requested technical support from another provider for a related matter?
If so, please specify which technical support provider you have contacted and briefly describe the support you
have requested as well as the status of the request.
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BACKUP Health – Application Form – Project Mode
Date:
Attachments to this application
Completed self-disclosure form
Registration documents
Detailed budget
Applicant’s signature (name, organisation)
Endorsement
Please note: In general, all applications should be endorsed by the CCM Chair or the CCM Vice Chair.
Please indicate who has endorsed the application.
Date:
Signature (name, organisation)
CCM Chair or
CCM Vice Chair
For GIZ Country Office use only
Date:
Quality checklist completed
Commercial suitability review completed
Country Director (name, signature)
For BACKUP Health use only
Date:
Committee approval
Application approved by:
BACKUP team (name, signature)
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BACKUP Health – Application Form – Project Mode
Proposal title
Applicant (Organisation, person responsible, contact details)
Budget (in EUR)
Country or region covered
Please note: The narrative part of the application (sections 1 to 7) should not exceed 10 pages excluding the
monitoring and evaluation tables.
1. Background information
1.1 Information about the applicant (Short description of the organisation, mission, office and steering structure; indicate
staff responsible for the proposed project in the table below)
Name
Role in project (project
manager, coordinator, trainer,
accountant, etc.)
Describe work experience
/ required profile
Time spent on project (in
% FTE1)
1.2 Country context (Provide a brief overview of the current situation – population, socioeconomic situation, health indicators,
disease burden, gender aspects – that requires technical support and, where possible, support this with evidence such as Global
Fund recommendations, conditions precedent, TRP recommendations, management letters, etc.)
1.3 Relevance of the applicant and the proposed project to national policies and Global Fund
mechanisms (Relationship to CCM and/or Principal Recipient, role in implementing Global Fund grants and/or national
programmes, involvement in national policy development or activities)
2. Project information
2.1 Areas of support (Please outline the project focus and how presumed impacts (the intervention logic) correspond to the
defined intervention areas described in the Downloads ‘General orientation and guidelines for Project Mode application’ and the
corresponding guidelines for each intervention area provided on the BACKUP website (www.giz.de/backup))
2.2 Beneficiaries
Direct beneficiaries (Indicate the people and groups of people who will directly benefit from the project activities, specifying
type and number. Where direct beneficiaries are organisations, indicate their involvement in developing the project.
Indirect beneficiaries (Indicate the people and groups of people not directly associated with the intervention who will
indirectly benefit from the project, specifying their type and estimating their number, where possible.
3.
1
Methodology (Please describe which approaches and methods will be applied. Which partners will be involved?)
Full-time equivalent
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BACKUP Health – Application Form – Project Mode
4
Monitoring and evaluation
4.1 Monitoring and evaluation matrix (This matrix will help to define the indicators required to measure your project’s achievements. Please define outcome, outputs, milestones and activities and
elaborate on the indicators. Examples for indicators and activities are described in the guidelines for each intervention area.)
Level
Indicators
Milestones
Means of verification
Assumptions/risks
Outcome
Output 1
Major activities
Output 2
Major activities
Output 3
Major activities
Definitions for ‘outcome,’ ‘output’ and ‘indicator’ are provided in the following downloads published by OECD, Development Assistance Committee:
 2002: Glossary of key terms in evaluation and results based management (0.6 MB pdf, in English, French and Spanish)
 1991: DAC - Principles for Evaluation of development assistance (1.19 MB pdf)
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BACKUP Health – Application Form – Project Mode
4.2 Schedule of activities (Please list the activities indicated in the monitoring and evaluation matrix in section 4.1 of the application. Q = quarter.)
Year 1
Activities
(including evaluation)
Q1
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Q2
Q3
Year 2
Q4
Q1
Q2
Q3
Q4
BACKUP Health – Application Form – Project Mode
5.
Special consideration of cross-cutting topics (Please describe how the proposed project addresses the needs of
key affected populations or considers gender equality. Alternatively, if the project will not impact on cross-cutting topics, please
explain why.)
6.
Continuity and sustainability (Indicate to what extent the benefits of the project will continue once the project activities
have come to an end and the conditions ensuring that the results of the activities are sustainable.)
7.
Budget (Please note: A completed budget must be attached to your application. If not, the application will not be further
processed.)
Download: Detailed budget – Project Mode (xlsx, 20 KB)
Please note, if your application is successful: All contracting partners shall be obligated to send a report in
electronic format to backup@giz.de every six months during the project period and a final report upon
completion of the project. Reporting forms are available on the BACKUP website (www.giz.de/backup) or
can be forwarded upon request.
For further information, please see the Downloads ‘General orientation and guidelines for Project Mode
application’ and the corresponding guidelines for each intervention area provided on the BACKUP website
(www.giz.de/backup).
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