Concept Note Form

APPLICATION FOR (only tick one of the options) 1. ☐PILOT GRANT OR 2. ☐SCALE UP GRANT
Contents
Section A: Eligibility self-assessment
Section B: About your organisation
Section C: Proposed project idea
Section D: Financial details
Section E: Environmental and Social Issues
Important Notes
  1. All questions on the form are required information. Your application cannot be considered without these items being completed or, in the case of numeric values, showing as non-zero. However, please provide as much information as you can as this will enhance your application. Please note that no figures/diagrams/photos can be inserted into the form. The only attachments accepted are (1) proof of legal registration, (2) auditied financial statements, and (3) letters of intent, MoUs or contracts with implementing partners if applicable. No other documents or attachments will be accepted.
  2. Once complete, please email the completed form in the same Microsoft Word Format in which the form was provided to . Please enter “HDIFROUND 2 APPLICATION” in theSUBJECTline of the email. Applications received by any other method will are not eligible.
  3. HDIF will acknowledge receipt by return email to the email address from which the application was sent.
  4. You may be contacted by HDIF to provide further information so please reconfirm that the contact email address entered in the form is correct, and if possible, send the application from the same contact email address. The contact email address entered on the form will be the email address for all communication once your application has been processed.
  5. If you have any problems with this form, please email us at .
  6. PLEASE SUBMIT YOUR APPLICATION BY 14 August 2015, 5:00 PM East Africa Time
Thank you and we wish you good luck with your application.

Section A: Eligibility self-assessment

ELIGIBILITY QUESTIONS / YES / NO
Organisation Type and Funding History
Applications must be submitted by the lead organisation. The lead organisation is the entity that will sign a Grant Agreement with HDIF if funds are awarded, will establish a GBP bank account to receive funds from HDIF, and will be held accountable to implementing and reporting on the HDIF-funded project.
A1 / Is your organisation the lead organisation for this proposal? / ☐ / ☐ /
A2 / Is the lead applicant or local implementing partner registered in Tanzania?
Please attach a copy of the Registration Certificate / ☐ / ☐ /
HDIF funds non-state actors. Public sector, multilateral and bilateral agencies (e.g., local government, ministries, government agencies, UN agencies, and government donor agencies) are not eligible. Public private partnerships may be supported, but the grant will not be awarded directly to a government institution (including parastatals or businesses wholly-owned by a government).
A3 / Is your organisation a non-state actor? / ☐ / ☐ /
Requests for funding should fit within the prescribed range for the competition and applicants are required to demonstrate their capacity to absorb and manage the funding requested. HDIF requires applicants to have completed at least 1 external audit as a pre-condition of funding.
A4 / Is your funding request within the prescribed range of GBP 150K-400K? / ☐ / ☐ /
A5 / Has your organisation managed a grant, contract or third-party debt/equity investment of this size before? (Third-party means that the funding did not originate from the managers of the lead applicant or an affiliated organization)
Please list the major third-party donors or investors who have funded your organisation within the last three years:
Please provide the following details for the largest grant or independent investment received to date:
Amount of grant or investment: £
Form (grant, debt, convertible debt or equity):
Project duration in years (if applicable): / ☐ / ☐ /
A6 / Are your annual gross receipts or gross revenue at least 30% of the total amount of funding requested from HDIF? (For example, if you are requesting GBP 150,000, are your annual gross receipts or gross revenue at least GBP 50,000)? / ☐ / ☐ /
A7 / If awarded, will this be the first grant from HDIF? / ☐ / ☐
If this will not be your first award from HDIF, will the funding requested in this competition be used for new idea or a different sector from your prior or current HDIF grant? / ☐ / ☐
A8 / Has your organisation undergone at least 1 external audit within the last two years?
Please attach a copy of your most recent audited financial statements. / ☐ / ☐
Grant Criteria
HDIF exclusively funds innovations. HDIF defines innovation as new to the world or new to Tanzania.
A9 / If your proposal is a PILOT, is your innovation new to Tanzania or new to the world? If your proposal is a SCALE UP, was your project new to Tanzania or new to the World before you implemented your current PILOT? (If you are not currently piloting the innovation, select ‘no’)
Please select the primary classifications of your innovation after reflecting on Doblin’s 10 Types of Innovation ( which HDIF uses to frame and evaluate innovations:
☐ Profit model
☐ Network
☐ Structure
☐ Process
☐ Product Performance
☐ Product System
☐ Service
☐ Channel
☐ Brand
☐ Customer Engagement
☐ None of these apply to my idea / ☐ / ☐
HDIF funding is restricted to the sevenresults areas in Health, Education, and WASH, as identified in the call for proposal. Applicants must have proven ability to deliver results in their target sector(s).
A10 / Does your proposed projectcontribute to one of HDIF’s seven results areas?
Which one:
☐ Improved quality of education & learning outcomes
☐ Improved access to education for girls and vulnerable groups
☐ Improved education management systems
☐ Increased child survival
☐ Improved quality of health services using low cost approaches
☐ Improved health systems management
☐ Sustainable access to water or sanitation through low cost approaches
☐ None of these apply to my innovation / ☐ / ☐
A11 / Has your organisation successfully implemented a project/programme in your proposed results area? / ☐ / ☐
A12 / Does your lead applicant or a known partner organisation have basic institutional capacity in monitoring and evaluation (M&E), including staff skills/experience, performance metrics, and functioning systems/tools for data collection and monitoring?
Which partner will perform the M&E functions for this innovation (insert name): / ☐ / ☐
HDIF only funds projects that are ready to implement. Untested ideas are not eligible for funding. Pilots may be funded after proof of concept.
HDIF does not fund research unless the research is applied directly towards improving the quality, value for money and sustainability of basic services in an eligible sector in Tanzania.
A13 / Is your proposed project ready for implementation? If one or more of the followingstatements applies, then select “No” in the box on the right:
☐ The innovative solution has not yet been prototyped or tested (e.g., it is an idea, a concept or you have heard about the innovation but not developed the solution)
☐ The lead applicant or its partners will need to acquire intellectual property rights from another organization and person in order to implement this project
☐ The lead applicant requires a partner to assist in specific activities during implementation but the partner(s) have not yet been identified.
☐The product or service has not yet been developed to a point where it can be readily consumed by the target market or beneficiary.
☐HDIF funding is required before the innovation can be demonstrated in person
☐ Funding is being sought for a research project where the proposed outcome is an advancement of knowledge/science but not an improvement in basic services
☐The project is a randomised control test
☐The project will be lead by a principal investigator or researcher, and there is no known partner to commercialize the innovation or ensure government adoption by the end of HDIF funding
☐ Is this application seeking funding to replace a current or former donor funding for the same project? / ☐ / ☐ /
Lead organisations may wish to engage an implementing partner for their proposed project. In addition, international organisations without a field office in Tanzania must arrange for a local implementing partner with sufficient capacity to implement the proposed project.
Lead organisations are required to obtain confirmation of intent to partner from their implementing partners. They must also demonstrate their ability to monitor the implementing partner and hold them to account.
A14 / Does the lead applicant or a proposed partner have a proven track record of successfully implementing similar activities/projects? / ☐ / ☐
A15 / Has your organisation obtained a signed letter of intent to collaborate, Memorandum of Understanding (MoU) or contract to partner from all proposed implementing partners?
Please attach a copy of such letter(s). / ☐ / ☐
Other Restrictions
Applications may only be submitted once.
A16 / Has your project idea only been submitted once in this round of competition? / ☐ / ☐
Terms and Conditions
The following are standard terms and conditions that apply to all grants awarded by HDIF without exception. Please confirm that these terms and conditions are acceptable before submitting an application.
A17 / Is your organisation willing and able to open a GBP bank account in Tanzania by the time of contracting in early 2016? / ☐ / ☐ /
If the answer to all the questions above is yes, then your organisation and project meet HDIF’s eligibility requirements. You may proceed with completing and submitting your concept note for consideration.
If the answer to any of the questions above is left unanswered, marked‘no’ or deemed by HDIF to have properly been marked ‘no’, your organisation or proposed project does not meet HDIF’s eligibility requirements. Please do not submit a concept note as ineligible applications will not be considered.

Section B: About your organisation

Organisation details
B1 / Organisation Name
B2 / Organisation short name
B3 / Postal address/P. O. Box
B4 / Physical address
B5 / Town/Area
B6 / City/County
B7 / Postal code
B8 / Country
B9 / Organisation telephone no.
B10 / Organisation email
B11 / Organisation website
Contact details (The single point of contact for the lead applicant to coordinate all HDIF communications)
B12 / Salutation / Choose an item.
B13 / Name
B14 / Job Title
B15 / Email address
B16 / Office number
B17 / Mobile number
Operational details
B18 / Briefly describe your organisation (What does your organisation do? Who owns it? Who manages it? Experience in managing this type of project.) Maximum 100 words
B19 / Year established
B20 / Annual gross receipts / £0
B21 / No. of full time employees / 0
B22 / No. of part time employees / 0
Registration details
B23 / Type of organisation / NGO (NGO, CSO, FBO, CBO, Trust, Foundation)
Private Sector/ Business
Research / Academic Institution
B24 / Country of registration
B25 / Registration number

Section C: Proposed project idea

Project details
C1 / Innovation idea title
C2 / Primary HDIF Results Area / Choose an item.
C3 / Implementation Region(s) & District(s)
C4 / Projected project duration (minimum 12 months and maximum 36 months) / 0months
Information about the project (Use the space wisely and avoid replicating information. Feel free to include web links to useful information but include the relevant information in the text of this concept note to ensure the HDIF reviewers know exactly what you want to convey.)
C5 / Executive Summary
Consider this section your pitch that summarise all the information in this concept note. Provide a simplified, concise problem that you are trying to solve in Tanzania within HDIF’s 7 results areas, what has been tried in Tanzania to solve this problem, why your innovation going to be more successful, a brief summary of the innovative solution that describeswhat is innovative about the idea and what the project intends to achieve. (Here’s one example of a guide for developing a pitch:
Please write here (250-500 words)
C6 / Innovation: The HDIF defines 'innovation' as an approach, idea, technology or serviced delivery method that is new to Tanzania and/or the world, or offers an improvement or scaling up.You may wish to refer to Doblin’s 10 Types of Innovation () used by HDIF to frame and evaluate innovations.
Mandatory inclusions in this answer are:
  • What new approach, idea, technology or serviced delivery method is being proposed for the first time in Tanzania/the world?
  • How is the innovation new to Tanzania and/ or to the world or offers an improvement or scaling up to an already existing concept in Tanzania or elsewhere?
  • How is this innovation differentiated from similar or competitive solutions?
  • How do you intend to implement this innovation? What is the high-level business plan?
  • Who will pay for this innovation during or after HDIF’s funding?
  • What do you understand about current demand for this solution among your target customers, users or beneficiaries? If a government agency is required to adopt your innovation for it to scale, does the current policy and budget support such adoption or how will you work to create government buy-in before the end of HDIF’s funding?

Please write here (300-500 words)
C7 / Developmental impact: Howwill your proposed project contribute to the objectives of HDIF and create meaningful benefits for large numbers of poor and vulnerable Tanzanians? *
Mandatory inclusions in this answer are:
  • What are the expected developmental impacts on HDIF’s targets: the poor, children under five, women and girls? What is your logic or results chain for how this innovation will translate into your expected development impacts?
  • How will you be able to measure your impact by the end of HDIF’s funding?
  • Who is the initial or current targeted customer or user? If they are not very poor or vulnerable, how will you work during implementation to ensure your innovation begins to target the very poor or vulnerable persons?
  • What are the major obstacles that must be overcome for your innovation to have its intended development impact? (These could be, e.g., a policy issue, ability to hire specific expertise, or financial sustainability of your organization)
  • What is your vision or hopes for how this innovation will be viable or sustainable (i.e., how will the innovation continue to have a development impact after HDIF’s funding)?

Please write here (250-500 words)
C8 / Organisational capability: Doyou and your known partners have the capacity to implement the project and deliver the innovation?
Mandatory inclusions in this answer are:
  • What governance, technical and financial capacity do you have to transparently, accountably and practically implement the project and deliver the innovation? Describe your team and how you plan to structure the implementation of this project.
  • What experience, if any,does the lead applicant and its partners have in implementing this kind of project?
  • What role(s) will each partner play in implementation?
  • Whatare your organizations and partnership/consortium’s competitive advantage and/or unfair advantage in implementing this innovation? (In other words, this may be a great innovation by why are you the right team to pilot or scale up the innovation?)
  • How will you manage your partners or consortium?
  • What, if any, engagement with government institutions is required to enable your innovation and how will your team be set up to engage in this work?

Please write here (250-500 words)
C9 / Describe the wider impact on innovation in Tanzania
Howwill your project contribute to creating an enabling environment for innovation growth in Tanzania? (This article may help stimulate your thinking about how you can have an impact beyond your own project: )
Please write here (100-300words)

Section D: Financial details

Total financing requirement for your innovative idea (GBP)
D1 / Total budget (HDIF funding + Counterpart funding) (D2+D6) / £0
Funds requested from HDIF for the proposed idea (GBP)
D2 / Grant requested / £0
Funds to be provided by your organisation, partners and third parties (i.e. counterpart funding (GBP)
D3 / Funds that your organisation and other partners will provide as new cash injections for your innovative idea. / £ 0
What is the source of these funds?
D4 / Financial value of resources that your organization and other partners will provide as 'in-kind' contributions for your innovative idea. / £ 0
What is the source of these funds?
D5 / Funds (e.g. bank loans) that other parties will make available for your innovative idea. / £ 0
What is the source of these funds?
D6 / Total counterpart funding (D3+D4+D5) / £ 0
D7 / % of counterpart funding(D6 / D1 x 100) / %
Expected use of HDIF Funds
D8 / List below main activities (not all) that you expect to finance through this requested grant:
1 / £0
2 / £0
3 / £0
4 / £0
Previous funding (from government and/or other donors)
D9 / Has the idea previously received any donor funding? / Choose an item.
D10 / If yes, please state the name of the donor organisation, the amounts of the funds received and the year the funds were approved.
Donor 1 / Donor 2 / Donor 3
Name of Donor
Amount (GBP) / £0 / £0 / £0
Year approved

Section E: Environmental and Social Issues

Environment and Social Impact
E1 / Will your project idea have an impact on the environment (positive or negative)? / Choose an item.
E2
5 / Provide further details about the potential environment risks of the project and explain how this will be mitigated
Please write here (maximum250words)
E3 / Provide details about the potential social risks of the project and explain how this will be mitigated
Please write here (maximum250 words)
Are there any circumstances, including personal, financial and business activities that will, or might, give rise to a conflict of interest by this organisation taking part in this competition or if awarded the grant? This also applies to any sub-contractors proposed by the Applicant.* / Choose an item.
Has this organisation or any of its sub-contractors been convicted of, or are the subject of any proceedings, relating to corruption including the offence of bribery and fraud / Choose an item.
Please click this box to indicate that you have read and accept the HDIF General Terms and Conditions as provided for in the Guidelines for this call for proposals.
Please let us know how you found out about HDIF / Choose an item.

Confidentiality Clause

HDIF agrees to regard as confidential all information attached to the application, and subsequent progress of the project that is not in the public domain. Only HDIF (and its staff and consultants), the UK Department for International Development, as the funder of HDIF, and members of the HDIF’s independent grants committee will have access to your application without your prior permission.

*HDIF reserves the right to reject any application that, in HDIF’s sole discretion, gives rise to or could potentially give rise to a conflict of interest.

HDIF Concept Note _ Round 2Page 1