Shaping our Future: Collaborating for a Healthier World

Partnership Forum Participant Nomination Form

Please complete all sections for each nominee:

Nominee Information:

Surname: / Given Name:
Email contact:
Telephone contact:
Mailing address:
Gender: / Male: ☐ / Female:☐ / Trans*/Other: ☐
Organization:
(if relevant)
Participant Group / Select one of:
Academia: ☐
Bilaterals: ☐
Board and Committees: ☐
CCM: ☐
Civil Society / Communities (International): ☐
Civil Society / Communities (National): ☐
Donors, Private Foundations and other donors: ☐
GFO: ☐
Implementer (PR/SR): ☐
LFA: ☐
Multilaterals: ☐
Parliamentarians: ☐
Private Sector: ☐
TRP: ☐
Region: / Select one of:
Global: ☐
Regional: Eastern Europe and Central Asia: ☐
Regional: South and West Asia ☐
Regional: East Asia and Pacific ☐
Regional: Latin America and Caribbean ☐
Regional: Middle East and North Africa ☐
Regional: East Africa and Indian Ocean ☐
Regional: Southern Africa ☐
Regional: West and Central Africa ☐
Nominated by: / Insert name of the nominating organization / individual or self-nomination
Contact person:
Email contact:
Telephone contact:
GF Secretariat Contact Person*
* leave blank if unknown

Rationale for Nomination:

  1. Please describe the rationale for this nomination and how this nominee will benefit from and contribute to the Partnership Forum. (Max 150 words)

Partnership Forum previous participation

  1. Please indicate if the nominee has attended a previous Partnership Forum:

Bangkok 2004 / ☐ / Durban 2006 / ☐ / Dakar
2008 / ☐ / Sao Paolo
2011 / ☐ /

Nominee qualifications and background

  1. Please indicate the level of the nominee’s current engagement and knowledge of the Global Fund and its Strategy. (Note: the Global Fund is equally interested in the participation of individuals who do not have the opportunity to engage through the standard channels.)

Level of Engagement: (please select one of the following)
Actively engaged:
(engaged daily or weekly, current member of a governing body, advisory group or Global Fund network) / ☐ / Occasionally engaged
(occasional participation in Global fund related activities) / ☐ /
Moderately Engaged
(engaged monthly or bi-monthly, former member of a governing body, advisory group or Global Fund network) / ☐ / Good knowledge but not actively engaged (familiar with Global Fund but not engaged through regular channels) / ☐ /
  1. Please describe the nature of the nominee’s current engagement and/or knowledge of the Global Fund and its Strategy. (Max 150 words)
  1. Please indicate the nominee’s primary disease/health focus

HIV / ☐ / Health Systems Strengthening / ☐ /
Tuberculosis / ☐ / Community Systems Strengthening / ☐ /
Malaria / ☐ / MNCH / RMNCH / ☐ /
Human Rights / ☐ / Gender / ☐ /
Other (please specify:) / ☐ /

Additional (Optional) Section

  1. Please indicate whether to your knowledge the nominee is a member of or represents the following population groups. Please notethat you may select more than one group (for example if someone is a young person who also uses drugs).

If you do not think the below section is relevant or if you have concerns about indicating the below then please leave this section blank. This information will be kept confidential to the Global Fund Secretariat.

Women / ☐ / Sex workers / ☐ /
Young people (aged 10-24) / ☐ / Prisoners / ☐ /
Refugees / ☐ / Migrants / ☐ /
Men who have sex with men / ☐ / People living with HIV / ☐ /
Transgender persons / ☐ / People living with TB / ☐ /
People who use drugs / ☐ / People living with Malaria / ☐ /
Other (please specify which community): / ☐ /

Thank you for completing this nomination form.

Please send the completed form to