|
applicant:
leave this blank IHRD office use only Year: ...................................... PD:............................................... Country:......................................... Application #: ............................. Date received: ............................. |
Open
Society Institute
International
Harm Reduction Development Program
1999-2000
Grant Program
Final
application form for applicants for
HIV
in Prisons Initiative
________________________________________________________________________
PLEASE
NOTE!
This
application should be sent to:
Kasia
Malinowska-Sempruch, IHRD, Director of Program Development, 400 W. 59th St.,
New York City, NY 10019, tel.: +1-212-548-06-77, fax: +1-212-548-46-17, Email:
ihrd@sorosny.org
The
application will be reviewed by IHRD in New York within one month of receipt.
1.
Information on the Applicant and Proposed Project
1.1 Name of the applicant: .................................................................................................................
1.2 Name of applicant organization: ..................................................................................................
1.3 Address: ..........................................................................................................................
City: ..........................................................................................................................
Country: ........................................................Postal code................................................
1.4 Phone: ................................ Fax: ................................ E-mail: .................................................
1.5 In two pages or less, provide a description of your goals, as they relate to the project on HIV in prisons. Please include a short summary of the problem in your city and information about the number of people you hope to reach.
1.6 Have you applied for funding from IHRD before? Yes [....] No [....]
If yes, please provide the name of that application and term:........................................................
Was this application awarded a grant by IHRD? Yes [....]
No [....]
What was the term of the grant? from .............................. to .............................................
Month/ Year Month/Year
1.7.1 Are there any other projects similar to the one described in this application in the city where the project is planned? Yes [....] No [....]
If yes, please answer the following questions to your best knowledge:
What is/are the name(s) Which organization is Where does funding for
of this/these project(s)? running this project? this project come from?
................................................ ....................................................... ...........................................................
................................................ ....................................................... ...........................................................
................................................ ....................................................... ...........................................................
1.7.2 Are there any other projects similar to the one described in this application in your country? Yes [....] No [....]
If yes, please answer the following questions to your best knowledge:
City What is/are the name(s) Which organization is Where does funding for
of this/these project(s)? running this project? this project come from?
.................... ..................................... .............................................. ........................................
.................... ..................................... .............................................. ........................................
2.
Scope of Activities of Applicant Organization*
2.1 Mission Statement and Activities of Applicant Organization
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
2.2 Is the applicant organization a non-governmental (NGO) or governmental organization (GO)?
NGO [....]
GO [....]
2.3 Funding History (List in chronological order, if applicable, grants received by the organization
seeking funding during the past five years, including pending applications.)
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
2.4 Affiliations with other non-governmental or governmental groups
Name of organization NGO/GO? Purpose/activities of organization
........................................... ................ .................................................................................
........................................... ................ .................................................................................
........................................... ................ .................................................................................
........................................... ................ .................................................................................
........................................... ................ .................................................................................
* Please submit any available documentation (annual reports, financial reports, articles, brochures, etc.) about your organization with your application.
3.
Personnel engaged on project, including consultants/collaborators
Name: ...................................................... Degree/Education: ........................ Position Title: ..................
Role on Project:........................................ Organization: .........................................................................
Name: ...................................................... Degree/Education: ........................ Position Title: ..................
Role on Project:........................................ Organization: .........................................................................
Name: ...................................................... Degree/Education: ........................ Position Title: ..................
Role on Project:........................................ Organization: .........................................................................
Name: ...................................................... Degree/Education: ........................ Position Title: ..................
Role on Project:........................................ Organization: .........................................................................
Name: ...................................................... Degree/Education: ........................ Position Title: ..................
Role on Project:........................................ Organization: .........................................................................
Name: ...................................................... Degree/Education: ........................ Position Title: ..................
Role on Project:........................................ Organization: .........................................................................
Name: ...................................................... Degree/Education: ........................ Position Title: ..................
Role on Project:........................................ Organization: .........................................................................
4.
Biographical Sketch of
Applicant/Program Director*
4.1 Education and Training
___________________________________________________________________________________
Institution and Location Degree Year Field of Study
___________________________________________________________________________________
............................................................... ..................................... ....... .......................
............................................................... ..................................... ....... .......................
............................................................... ..................................... ....... .......................
___________________________________________________________________________________
*Applications without biographical sketch/resumes will not be accepted.
4.2 Professional Experience
(Concluding with present position, list in chronological order previous employment, experience, activities (paid or voluntary), and honors relevant to the proposed project.)
___________________________________________________________________________________
Year Position
___________________________________________________________________________________
.......... ..................................................................................................................................................
.......... ..................................................................................................................................................
.......... ..................................................................................................................................................
.......... ..................................................................................................................................................
.......... ..................................................................................................................................................
.......... ..................................................................................................................................................
.......... ..................................................................................................................................................
.......... ..................................................................................................................................................
___________________________________________________________________________________
4.3 Relevant Publications
5.
Executive Summary (no longer than one full page; attach sheet if
necessary)
5.1 Problem
(A brief statement of the problem or need your agency has recognized and is prepared to address. One or two paragraphs.)
5.2 Approach taken by your proposed project to address the problem
(A short description of the project. One or two paragraphs.)
5.3 Funding requirements
(An explanation of the amount of grant money required for the project and what your plans are for funding it in the future. One paragraph.)
5.4 Organization and its expertise
(A brief statement of the name, history, purpose and activities of your agency, emphasizing its capacity to carry out this proposal. One paragraph.)
6. Project Description (please type on a separate page)
6.1 Specific Aims
(Describe what exactly is the goal of the project; be as specific as possible. Not to exceed 1/2 page.)
6.2 Background and Significance
(This section should describe clearly why the project is needed. What is the problem/situation to be addressed? Provide available research data + sources. Why is this project the best approach to address the problem? Not to exceed three pages. Additional information, relevant research, and reports may be added as appendices.)
6.3 Progress Report (for continuation application only)
6.4 Project Design, Methods, and Implementation Time Line
(Clearly describe the design of the project. Justify choice of methods; have these been successfully applied elsewhere? What does the work consist of, what services will be provided? Specify the specific role of each member of the project staff. What is the role/function of the budgeted equipment, materials, and supplies? Provide a time-frame for the project. Please specify training activities -topic of training, number of participants, description of trainers, etc. This section not to exceed 4 pages.)
6.5 Sustainability
(Describe your strategy for ensuring the continuation of the project once funding from IHRD is no longer available.)
7.
Literature cited in Project Description
8.
Appendices
9. Self-evaluation
component*
In this section you should explain how you plan to measure the success rate of your project (for example, number of needles exchanged, number of patients reached through drug substitution, etc.)
Attach supplementary sheets as necessary.
*Applications without a self-evaluation component will not be accepted
10.
Funding requested from IHRD and funds from other sources
10.1 Please indicate the total amount requested from IHRD for this project: $____________________
*this sum should be identical to “Total Budget All Categories: Funding requested from IHRD”, see 11.8 below.
10.2 Please identify the other funder(s) (in addition to the local Soros National Foundation) which has (have) provided or may provide funds or in-kind support (estimate dollar value) for this project.
(a) ______________________________________________________________________________
Name of Organization
Address
Tel, Fax and/or Email
______________________________________________________________________________________
Name of Person to Contact Address Tel, Fax and/or Email
Amount or in-kind support requested or available (check one box) from this funder: $____________________
(b) ______________________________________________________________________________
Name of Organization
Address
Tel, Fax and/or Email
______________________________________________________________________________________
Name of Person to Contact Address Tel, Fax and/or Email
Amount or in-kind support requested or available (check one box) from this funder: ` $____________________
List supplementary funders as needed.
10.3 If monies are available from other funders (i.e. other than IHRD or local Soros National Foundation) at the time of application, you should attach to this application an endorsed letter from the funder(s) detailing the amount granted, the purpose, and the term of the grant.
Note: In the event of a successful application, IHRD will only allocate a grant if equal matching funds from the local Soros National Foundation are forthcoming.
11.
Detailed Budget
11.1 Project Personnel Dollar amount requested (omit cents)
|
Name |
Role in Project |
Number of hours worked on project per week |
Current salary per month (if employed) |
Additional salary requested to work on this project |
Funds requested from IHRD to cover additional salary |
Funds requested from local Soros National Foundation |
Funds requested or available from ALL other sources |
|
|
|
|
$ |
$ |
$ |
$ |
$ |
|
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|
$ |
$ |
$ |
$ |
$ |
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|
$ |
$ |
$ |
$ |
$ |
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|
$ |
$ |
$ |
$ |
$ |
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|
$ |
$ |
$ |
$ |
$ |
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|
|
|
$ |
$ |
$ |
$ |
$ |
|
|
|
|
$ |
$ |
$ |
$ |
$ |
|
Subtotals Project Personnel |
XXXXXXXXXXXXXXX |
XXXXXXXXXX |
$ |
$ |
$ |
$ |
$ |
* Salaries must be based on guidelines or average salary for this or similar positions in your country (If in doubt, please discuss with the local Soros National Foundation. Please provide documentation).
11.2 Harm Reduction Supplies and Materials (itemize by category; e.g. needles, condoms, test kits, etc.)
|
Item |
Function in Project |
# of Units |
Unit Price in US $ |
Total |
Funds requested from IHRD |
Funds requested from local Soros National Foundation |
Funds requested or available from ALL other sources |
|
|
|
|
$ |
$ |
$ |
$ |
$ |
|
|
|
|
$ |
$ |
$ |
$ |
$ |
|
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|
$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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|
$ |
$ |
$ |
$ |
$ |
|
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|
|
$ |
$ |
$ |
$ |
$ |
|
Subtotal Supplies Costs |
XXXXXXXXXXXXXXXXX |
XXXXXXXXXXX |
XXXXXXXXXXXX |
$ |
$ |
$ |
$ |
11.3
Office equipment (itemize; e.g. computer, modem, etc)
|
Item |
Function in Project |
# of Units |
Unit Price in US $ |
Total |
Funds requested from IHRD |
Funds requested from local Soros National Foundation |
Funds requested or available from ALL other sources |
|
|
|
|
$ |
$ |
$ |
$ |
$ |
|
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|
|
$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
$ |
|
Subtotal Equipment Costs |
XXXXXXXXXXXXXXXXX |
XXXXX |
XXXXXX |
$ |
$ |
$ |
$ |
11.4 Administration and Office Supplies (itemize clearly, e.g. telephone calls, mail, internet, paper, pens, photocopies, etc.)
|
Description |
Total |
Funding requested from IHRD |
Funds requested from local Soros National Foundation |
Funds requested or available from ALL other sources |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
Subtotal administration and office supplies costs |
$ |
$ |
$ |
$ |
11.5 Training of Personnel (itemize)
|
Please list each training activity below (include a detailed description of the training program under section 6.4 of the application form) |
Total |
Funding requested from IHRD |
Funds requested from local Soros National Foundation |
Funds requested or available from ALL other sources |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
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$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
Subtotal
Training Costs |
$ |
$ |
$ |
$ |
11.6 Other Project Expenses (itemize)
|
Description |
Total |
Funds requested from IHRD |
Funds requested from local Soros National Foundation |
Funds requested or available from ALL other sources |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
|
$ |
$ |
$ |
$ |
|
Subtotal other project expenses |
$ |
$ |
$ |
$ |
11.7 Conference or Workshop Organization or Attendance
|
Description of Conference or Workshop: |
Total |
Funding requested from IHRD |
Funds requested from local Soros National Foundation |
Funding requested or available from ALL other sources |
|
conference venue rental |
$ |
$ |
$ |
$ |
|
simultaneous translation |
$ |
$ |
$ |
$ |
|
printing (e.g. conference announcement) |
$ |
$ |
$ |
$ |
|
conference reader |
$ |
$ |
$ |
$ |
|
translation/proof reading of literature |
$ |
$ |
$ |
$ |
|
lay out and printing |
$ |
$ |
$ |
$ |
|
mailing, postage |
$ |
$ |
$ |
$ |
|
secretariat/administration |
$ |
$ |
$ |
$ |
|
hotel accommodation |
$ |
$ |
$ |
$ |
|
travel local speakers |
$ |
$ |
$ |
$ |
|
travel foreign speakers |
$ |
$ |
$ |
$ |
|
other costs (specify) |
$ |
$ |
$ |
$ |
|
attendance of applicant-accommodation costs |
$ |
$ |
$ |
$ |
|
attendance of applicant-travel costs |
$ |
$ |
$ |
$ |
|
attendance of applicant-conference fees |
$ |
$ |
$ |
$ |
|
Subtotal conference organization or attendance |
$ |
$ |
$ |
$ |
11.8 Budget Totals
|
|
TOTAL |
Funding requested from IHRD |
Funds requested from local Soros National Foundation |
Funding requested or available from ALL other sources |
|
Subtotal
Project Personnel |
$ |
$ |
$ |
$ |
|
Subtotal
Supplies and Materials |
$ |
$ |
$ |
$ |
|
Subtotal
Equipment |
$ |
$ |
$ |
$ |
|
Subtotal
Administration and Office Supplies |
$ |
$ |
$ |
$ |
|
Subtotal
Training of Personnel |
$ |
$ |
$ |
$ |
|
Subtotal Other
Project Expenses |
$ |
$ |
$ |
$ |
|
Subtotal
Conference or Workshop Organization or Attendance |
$ |
$ |
$ |
$ |
|
TOTAL ALL
BUDGET CATEGORIES |
$ |
$ |
$ |
$ |
12. Budget Justification (use additional pages if necessary)
For all applications: Describe, explain and justify the specific functions of the personnel, collaborators, and consultants, and the budgeted time. Explain and justify purchase of equipment and supplies.
For continuation applications: Identify with an asterisk (*), describe and justify any significant increases or decreases in any category compared to the current level of support.