application forms by pengxiuhui


									                                Application Form - Consultancy Mode
Name of applicant:
Institution / Organisation:
Are you a Global Fund                   Principal Recipient or       Sub Recipient
If so, which grant(s)?:
Are you a                               CCM or         CCM member
Which constituency do you represent?
    academic/training institution                           national government institution
    international civil society organisation                private sector organisation
    national civil society organisation                     regional initiative
    multilateral organisation

Country or region covered:

Time frame of the intervention:
Start: (please enter specific date            End: (please enter specific date or       Period: (please enter
or month)                                     month)                                    number of days or months)

Disease(s):             HIV/AIDS

Applicant’s signature (date, name, organisation)


Signature (date, name, organisation)

Please note: In general, all applications should be endorsed by the CCM Chair. If the applicant is the CCM
itself, the application should be endorsed by the CCM Vice Chair. If the applicant is a Global Fund Sub
Recipient, the application should be endorsed by the CCM Chair or the respective Principal Recipient.
Please indicate who has endorsed the application:
                              CCM Chair,    CCM Vice Chair or     Principal Recipient

For GIZ Country Office use only

      Quality checklist attached and                          _____________________
      approved for further processing by                      Country Director (date, name, signature)

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                               Application Form - Consultancy Mode
Terms of Reference (TOR)

Title of consultancy:

1.    Executive summary (Please wrap up key elements of the consultancy)

2.    Background/Rationale

Why is this consultancy/study/appraisal necessary?

How will this activity strengthen capacities for a more effective Global Fund grant management?

How will the proposed activity contribute to Health Systems Strengthening, Community Systems
Strengthening and a gender-oriented approach?

3.    Objective of the consultancy (Please specify the objective and the outcome of this consultancy)

4.    Specific tasks (Methodology: e.g. orientation meetings, review of documentation and literature, interviews, workshops)

                                                                                                                     No. of
No.          Task/Activity (Please list and describe each task/activity          Remarks                         reimbursable

Report writing

Total no. of reimbursable days

The consultancy will be completed by (date):

5.    Deliverables of the consultancy (e.g. report, recommendations, guidelines, training manuals)

6.    Required profile and qualifications of consultant

7.    Proposed budget

Please note:
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                         Application Form - Consultancy Mode
    1) When completed, an electronic version of the BACKUP report must be sent to
       Reporting forms are available on the BACKUP website or will be forwarded on request.
    2) Negotiation of daily rates and contracting are handled by GIZ;
           For local consultants: rates and contracting handled by GIZ Country Office,
           For international consultants: rates and contracting handled by the German BACKUP
               Initiative, GIZ Head Office in Eschborn/Germany

For further information please see BACKUP guidelines for application (0.19 MB pdf).

                                                  Page 3/5
                                Application Form - Consultancy Mode
Quality checklist (for GIZ Country Office use only)

1.     Application forms                         A complete set of application forms has been submitted:
                                                  correctly signed application form
                                                  TOR

2.     Content of proposed intervention          Title:

2.1    These points are clearly stated           Context of intervention
                                                 (ongoing processes, current opportunities etc.)

                                                 Objective of intervention
                                                 (Why is this intervention needed? What does it intend to achieve?)

                                                 Relevance to funding from Global Fund
                                                 (anticipated contribution to global financing proposal or implementation,
                                                 leveraging of global initiatives)

2.2    Ratings of expected contribution          Health Systems Strengthening
                                                 (contribution to one or more of the six WHO building blocks?)
       (1 = none, 2 = indirect, 3 = direct)
                                                 Community Systems Strengthening
                                                 (contribution to organisations of people living with a disease
                                                 (AIDS, Malaria, Tuberculosis) and/or marginalised, criminalised?)

                                                 Gender-oriented approaches
                                                 (contribution to gender-sensitive or gender-transformative
                                                 approaches ?)

3.     Compatibility                             National policy and strategy
       The proposal is in line with these        (National Health Sector Strategic Plan, Poverty Reduction Strategy,
                                                 HIV/AIDS Policy and Strategy)
       guidelines and principles:
                                                 International principles and goals
                                                 (country-led, process-oriented, added value, impact orientation,
                                                 Millennium Development Goals, Universal Access, Three Ones)

4.     Capacity of partner to implement          Staff
       proposed activities
                                                 Organisational set-up
       (1 = moderate, 2 = good, 3 = excellent)
                                                 Evidence of transparency and accountability

5.     M&E                                       TOR are clear and reasonable

                                                 Time schedule is reasonable

                                                 Provision is made for capturing evidence and
                                                 experience of ‘good practice’

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                                    Application Form - Consultancy Mode

6.      Important caveats                     Technical cooperation
                                              (The proposed intervention does not cover activities that are part
                                              of GIZ-supported projects or programmes.)

                                              GIZ International Services (GIZ-IS)
                                              (The proposal does not interfere with GIZ-IS acquisition processes.
                                              There is no conflict of interest.)

7.      The proposal                          is ready for submission to BACKUP team
                                              at GIZ Head Office in Eschborn/Germany

                                              requires further amendments (see comments)

8.      Comments, recommendations, risks:

Assessed by

(date, name, position, signature)

Please note: A specific reporting form must be completed by the applicant/consultant. Reporting forms are
available on the BACKUP website or will be forwarded on request.

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