Uganda Program for Human and Holistic Development (UPHOLD)
Family and Community Action Grants – Part II
Application
2007
Important Notice:
In order to successfully complete this application, please be sure to have read and complied with the instructions in the Request for Applications (RFA).
Before Submission, please tick to make sure you have included the following:
Copy of Current Registration
Letter of support signed by CAO or his designate as the representative of the local government (Please note that for grantees covering multiple districts, a letter from each district CAO is required)
Most recent audited statement and/or references from recent donors
If applicable, signed letter of commitment from all partner organisations
2 copies and one original of the filled and sealed application form
This section to be filled out by the UPHOLD Regional office:
Office Received:
Time and Date received:
District:
Technical Area:
Proposal tracking number:
Part A: General Information
A.1. Name and Address of Organisation
Name of Organisation: ______
______
P.O. Box: ______Town/City/Village: ______District: ______Tel: ______Fax: ______Email: ______
Physical Address (Street, Village/Zone, Sub-county): ______
______
A.2. Name of Partner Organisation(s) (if applicable – please include current address)
a) Name of Organisation: ______
______
b) Name of Organisation: ______
______
A.3. Contact Information for this Grant Application (This should be a responsible officer who can commit on behalf of the Organisation)
a) First Contact Person
Name and Title of Contact Person ______
P.O. Box: ______Town/City/Village: ______District: ______Tel: ______Fax: ______Email: ______
Physical Address (Street, Village/Zone, Sub-county): ______
______
b) Second Contact Person
Name and Title of Contact Person ______
P.O. Box: ______Town/City/Village: ______District: ______Tel: ______Fax: ______Email: ______
Physical Address (Street, Village/Zone, Sub-county): ______
______
A.4. Type of Organisation
Lead Organisation: (tick one) / If applicable, Partner Organisation(s):a) Non-government organisation:
Indigenous non-governmental organisation ____
International non-governmental organisation___
Faith based organisation ____
Community based organisation ____
b) Private sector (for profit) ______ / a) Non-government organisation:
Indigenous non-governmental organisation ___
International non-governmental organisation__
Faith based organisation ______
Community based organisation ____
b) Private sector (for profit) ______
c) Other ______ / c) Other ______
Project Title
What is the title of your proposed project? ______
______
A.5. Total Budget
What is the total budget you are requesting from UPHOLD (in Ugandan shillings)? ______Please note that this should match the budget figure on page 20 of this application and not exceed amounts listed in Table A of the Request for Applications (RFA).
A.6. Registration and Partnership Documentation
A copy of the lead organization’s current registration MUST be attached.
Each partner organisation must submit a signed letter of commitment. Please attach to this application.
Attach the letter of support from the district government (see sample at end of application).
A.7. District focus
Please circle the district in which your activities will be implemented:
Arua / Ibanda / Kiruhura / MbararaBundibugyo / Isingiro / Kyenjojo
Are you submitting a grant application in another district? Yes or No
If yes, where? ______
A.8. Technical Areas and Indicators
Page 4 of this RFA describes UPHOLD’s technical areas. Listed below are some of the indicators UPHOLD is tracking. Please tick the indicators to which your proposed project will contribute.
HIV/AIDS□ Number of adults 15-49 requesting an HIV test at USAID supported HCT sites and receiving counselling, test and results (excludes PMTCT sites)
□ Number of all HCT clients that register as a couple
□ Number of pregnant women receiving HIV counselling, testing and their results
□ Number of individuals reached with abstinence and be faithful messages
□ Number of individuals reached with Prevention other messages
□ Number of individuals who receive HIV-related palliative care (excluding HIV/TB) – this includes individuals reached through community-based and home-based care programs
□ Number of HIV+ clients who receive TB treatment as palliative care related to HIV/AIDS
A.9. Social Transformation Areas
Briefly describe activities that will address social transformation issues in your proposal as per the guidance in the RFA appendix A It is important that you have read the RFA Part 2, to understand what is required in this section.
Part B: Organisation Profile
B.1. Background
a) Please tell us the date (month and year) your organisation was established.
Month: ______Year: ______
b) Briefly describe what work your organisation does. What are your main activities?
______
______
______
______
______
______
B.2. What Resources Does the Lead Organisation Have?
a) If you have an organisational chart of your organisation please attach it to this application.
b) Does your organisation have a Board of Trustees? Yes ______No ______
c) If yes Please write their names and contact information.
______
______
______
______
b) How many paid employees do you have?
Full time: ______Part time: ______Total: ______
c) How many volunteer staff do you have? ______
d) Does your organisation have office space? ______
e) Does your organisation have a bank account? ______
If yes, which bank? ______
f) How many bicycles, motorcycles or vehicles do you have?
Bicycles: ______Motorcycles: ______Vehicles: ______
g) How many computers, printers or photocopiers do you have?
Computers: ______Printers: ______Photocopiers: ______
h) What other key office equipment do you have? (eg. Lab equipment, refrigeration, generator, training equipment, typewriters etc) ______
______
______
B.3. Project Implementation History
This page should be filled out by each organization in the partnership.
a) Have you implemented any projects in the last two years? Yes _____ No _____
b) If yes, please provide the information below for each project you have implemented in the last two years. If you need more space for additional projects, please photocopy this page, fill it out and attach to this application. Please do not submit more than 5 projects per organisation.
Organisation NameProject Name
Project Objective
Activities undertaken
Geographic Location (district, sub-county, village, parish)
Name and address of donor and name of project contact and phone number
Period of Implementation
Total project budget
Results Statement
A strong results statement includes the number of people who benefited in a specific way from the project. It is a description of the changes or improvements that occurred due to the project.
Project Name
Project Objective
Activities undertaken
Geographic Location
Name and address of donor and name of project contact
Period of Implementation
Total project budget
Results Statement
Project Name
Project Objective
Activities undertaken
Geographic Location
Name and address of donor and name of project contact
Period of Implementation
Total project budget
Results Statement
Project Name
Project Objective
Activities undertaken
Geographic Location
Name and address of donor and name of project contact
Period of Implementation
Total project budget
Results Statement
UPHOLD Grant Application Page 2 of 24
Part C: Project Description
This section will describe the proposed project that you wish UPHOLD to fund. Answer all sections completely if you wish to be funded.
C.1. Activities
Please study the UPHOLD RFA (especially Appendix A, B) to be sure that your proposed project responds to the technical areas and interventions called for in your district. Please list the activities that you will carry out in the proposed project. Failure to respond to appropriate district technical areas could result in disqualification.
(a) Briefly describe the roles of each partner as they apply to this application.
(b) UPHOLD is interested in using its grants both to complement existing activities as well as avoid duplication. In consideration of this issue, please list other organizations that are providing similar services in your proposed project area over the proposed implementation period.
Name of organisation / Geographic focus / Technical areasUPHOLD Grant Application Page 2 of 24
C.2. Objectives and Target Setting
Please be sure to review the targets for each indicator in Part 3 of the RFA, in a Table indicating Technical Areas, Targets and \Resource Allocations in per distrit . In this section targets are specified for each indicator by district. Use indicators that are listed for the districts you plan to work in. It is important that the indicator you choose is directly related to your activities. It is also important that your chosen activities are likely to produce the targets that you have chosen in as cost-effective manner as possible. For more information regarding objectives and target setting, see Appendix B at the end of this application.
Objectives should be specific, measurable, achievable, realistic, and time-bound. For example:
1. By the end of March 2008, 8,000 couples will have been reached with Be faithful messages in the Sub counties of Kasambya, Bubulo, Kasambya Town Council, Kasenyi, Busungu, Bulungi , Karuutu, Mukuto, Ndibalaba
Table C.
Objective No. / Population affected by the problem in the project area. Give a number(if information is available, please provide. If not, leave blank).
. / Describe the target population.
Be as specific as possible (for instance, school going youth, orphans, out of school youth, men, women, children etc.) / Number of people in target population currently receiving or benefiting from service
(if information is available, please provide. If not, leave blank). / Number of additional people that will be reached by each objective of your project / State the specific objective
(This is a statement of how much of the target associated with an indicator you wish to be responsible for, given the activities you plan to implement.)
1
2
3
4
C.3. Workplan
Fill in the following table. (Please use the same objectives listed in the previous section.) After you complete this section and you discover the need to adjust the targets in your objectives in Section C2, please do so. It is important that your chosen activities are likely to produce the targets. Also note that the activities listed here should coincide with the areas ticked in Section A.8 and the activities described in section A.9.
EXAMPLE WORKPLAN – This is for illustrative purposes only and is not exhaustive.
Table D
No / Activities / Expected Results(State specific outputs that are verifiable and the direct result of the activity.) / Time Frame / Responsible person / Total Cost /
Year 1 (Months) /
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 /
Objective 1: By the end of the year, 3,500 Women (15-49) in Buyanja, Ruhinda, Kagunga, Nyakagyeme, Town Council, Kebisoni, and Buhunga sub counties in Rukungiri. will be using modern contraceptives.
1 / Activity 1.1: Strategy meeting with advisory committee (20 pple). To analyse factors affecting delivery of RH services in Rukungiri and draw up a plan how to address them. / X / Programme Coordinator / 1,528,000
2 / Activity 1..2: Workshops for community leaders to raise awareness about Reproductive Health issues and advocate for and support the programs at District, sub-county and community levels / 70 Community leaders equipped with correct information on RH to enable them to advocate for RH activities and support the CRH in their work.
Sensitize leaders to mobilise their communities for selection of their CRHWs / X / X / X / Programme Coordinator / 1,812,000
3 / Activity 1.3: Selection of Community reproductive Health workers.( 2 CRHWs per parish for 42 parishes / 84 Community
Reproductive Health Workers would have been selected / X / DDHS,
Coordinator / 1,500,000
4 / Activity 1.4: Training of community based
reproductive health workers in:
· Communication skills
· Couple counselling.
· Danger signs of pregnancy
· Referrals
· Follow-up visits
· Record keeping and Reporting
· Distribution of Family
Planning commodities / 84 CRHWs will have been equipped with relevant knowledge and sufficient skills to advise mothers families and communities on the importance of RH issues / X / X / Program Co-ordinator / 12,348,000
No / Activities / Expected Results
(State specific outputs that are verifiable and the direct result of the activity.) / Time Frame / Responsible person / Total Cost /
Year 1 (Months) /
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12
UPHOLD Grant Application Page 12 of 24
C.4. Monitoring Tools and Activities
UPHOLD and the districts have standard tools for collecting data on indicators outlined in part 3 of the RFA. Briefly describe your management plans to use these tools and activities proposed to track and report on expected results of your intervention.
C.5. Additional Considerations
a) UPHOLD is interested in understanding how you select actual project participants/beneficiaries. We would like to understand that you take care of the most disadvantaged, how you manage gender balance, and how you avoid duplication of efforts. It is important that your project involve stakeholders in its implementation. UPHOLD is also interested in establishing how you involve beneficiaries, local leadership and other donors.
b) UPHOLD is committed to working with grantees to increase capacity as needed. As such efforts will be directed towards providing support in project planning, project implementation (at community level and health facilities), monitoring and evaluation and financial management. Briefly describe the support you feel is critically needed by your organisation to implement this grant.
C.6. Detailed Budget
The project period should be one year. Table A and B of the RFA on p. 5 - 9 shows the technical areas for each district and the number of grant awards and amount allocated for each technical areas. CSOs that are able to cover more than one district should clearly list the districts and specific locations (counties, sub counties etc where they intend to carry out activities). If your organisation has audited statements, please attach a copy of the most recent one to this application. If your organisation has never received an audit, then make sure Part B, section 3 of this application has complete donor contact information.
Budget Considerations
Outlined below is a budget format that should be used to cost your application. An Excel version of this budget framework can be found on the UPHOLD website http://www.uphold.jsi.com
UPHOLD will not fund the purchase of vehicles, pesticides, construction of new buildings, and prescription pharmaceuticals. Major capital expenditures of general office equipment, motorcycles, and bicycles will be considered only if they are required for the successful completion of the project. Otherwise they are discouraged. Also, although UPHOLD encourages faith-based organisations to apply for funding, our funds cannot be used to support activities with significant religious or proselytizing purpose or content.