Peace Corps Small Grants Application Form

This form was updated on 4-23-2013
Peace Corps Small Grant Application

This application has been developed as a tool to help Volunteers and their communities plan
successful small grant projects. The information that you record here will also be transmitted to
Peace Corps Headquarters for internal reporting and reporting to donors.
Please work with your community to fill out this application and return it to the appropriate staff
member at post for review. You can use either the links on the table of contents or the menu at the
left to navigate between sections. Before completing any section, make sure to read the entire
application. Please check each box as you complete the section.
Table of Contents
Application Instructions
1. Project Classification
2. Project Description
3. Goals and Objectives
4. Timeline
5. Monitoring and Evaluation
6. Do No Harm
7. Detailed Budget
8. Grant Type Selection Menu
9. Signature Forms
Form PC-2105
Instructions on this Application

CELL COLORS:
BLUE CELLS
To be filled out by the community partner with the help of the PCV
PINK CELLS
To be filled out by post staff
BROWN CELLS
Will automatically populate based on information entered in

elsewhere in the application
COMMENTS ON CELLS:
Please take note of the red triangle at the top right corner of certain cells (including this one).
These have been included on many cells to help guide users through each step of the process.
HOW TO START A NEW PARAGRAPH IN A CELL:

If you want to start a new line within the same cell, you must hit "Alt + Enter"; simply hitting
"Enter" will jump to the next cell.
PROTECTED CELLS:
Each one of these sheets is protected and will allow data only to be entered in areas that are
shaded in pink or blue. This is done to ensure that all data entered is of the correct type to be
used in reporting within Peace Corps.
PRINTING THIS APPLICATION:

The pages in this workbook are set up to be printer-friendly. The default settings will print only
the sheet you are on. If you would like to print the whole workbook at the same time, go to "File
> Print" and under "Print what" select "Entire workbook."
Form PC-2105

1. Project Classification and Budget
Country:
Fiscal Year:
Project Funding Source:
Project Number:
Project Title:
Project City/Town/Village:
Region:
Community Group Name:

Group Contact Person:
Community Group Contact Information
(phone, address, etc.):
Total Days
Project Start Date:
Months
1 0.0333333333 0
Project End Date:
Weeks
D
ay
s
Number of PCVs:
Volunteer Information:
Last Name
First Name
Peace Corps Sector
COS Date
Names of Other PCVs Involved in Project

Planning or Implementation:
Primary PCV
PCV 2
PCV 3
Responsible Program Manager/APCD:
Project Classification
(Mark only one classification with "XX" as the primary classification of this project. Mark additional applicable descriptors with an "X.")
Agriculture
Municipal Development
HIV/AIDS
Food Security
Education
Community and Economic

Development
ICT
Gender and Development
Environment
Youth Development
NGO Development
Health
Water and Sanitation
Volunteerism
Form PC-2105
Males
Females
25 years old and 15 to 24 years

above
old
Under 15 years
old
25 years old
Under 15 years
15 to 24 years old
and above
old
Total
# of Participants (direct):
Community members directly involved in the design
and implementation of the project, including those
who attend trainings or workshops
# of Beneficiaries (indirect):
Community members who receive an indirect benefit
from the project, not including those counted above
Project Cost Breakdown (in U.S. Dollars)

(this will auto-fill based on information you enter in the detailed budget screen)
Grant Contribution
Community Contribution
Cash
Cash
Third-Party Contribution (if

applicable)
In-kind
Cash
In-kind
Labor
$0.00
$0.00
$0.00
$0.00
$0.00
Equipment
Materials/Supplies
Land/Venue Rental
Travel, Per Diem, Food
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Materials Transport
$0.00
$0.00
$0.00
$0.00
$0.00
Other
$0.00
$0.00
$0.00
$0.00
$0.00
Total
$0.00
$0.00
$0.00
$0.00
$0.00
All Volunteers should reference the

Peace Corps Small Grants Volunteer
Handbook which specifically outlines
allowable and unallowable costs.
Budget Narrative
Please provide a general list of what items or services will be funded.
Grant Contribution
Labor
Equipment
Materials and Supplies
Land/Venue Rental
Travel/Per Diem
Materials Transport
Other: (be specific)
Form PC-2105
Third-Party Contribution
(if applicable)

2. Project Description
Directions
Your descriptions should be between 150 and 250 words. Please be succinct in describing your project and clearly outline the project's sustainability,long-term need, and the level of
community support for the project. Keep in mind that your application may be shared or distributed to donors and the agency.
1) Please provide a brief summary of the project (up to

250 words). Include project objectives, the
community's contribution and the potential impact the
project may have. (For PCPP, this will be posted on the
Peace Corps website. For safety and security reasons,
please do not include the specific village name or any
personal identifying information.)
Summary
2) Describe the background of the community, and

what priority this project addresses. (Is this a priority
project identified by the community? Why is this
project needed?)
Background
3) How is the community the driving force behind the

project? Provide examples that demonstrate the
communitys involvement in the design and planning of
this project.
Community
Involvement
4) Briefly describe the desired outcome of the project.
Outcome
Form PC-2105
5) Describe the implementation plan that will be used

to achieve the goals and objectives of this project. Do
you foresee any challenges to project implementation?
Implementation
6) How will the project contribute to building skills and

capacity within the community?
Capacity Building
7) How will the community be able to sustain the

activities and/or benefits of this project? What is the
community's plan to sustain the benefits of the project
after the initial material support has ended?
Sustainability
Form PC-2105

3. Goals and Objectives
Directions
What are the project's goals and objectives, and how will you know if your project is reaching them to produce the desired
benefits or change?
-- Use the tables below to state the project's goals and objectives and show how you will measure and evaluate the success
of your project. Establishing this during the planning phase of your project is essential for the community to measure its
success against the intended results.
-- At least one of your objectives should support your country program goals and strategies.
-- Your Goals & Objectives should contain your project targets, and may be useful for the program-specific Indicators section
later in this application.
-- You will report on these measures in the completion report.
Goal 1:
Objective 1.1
Objective 1.2
Objective 1.3
Objective 1.4
Goal 2:
Objective 2.1
Goals &
Objectives
Objective 2.2
Objective 2.3
Objective 2.4
Goal 3:
Objective 3.1
Objective 3.2
Objective 3.3
Objective 3.4
Form PC-2105

4. Timeline
Directions
Please include a detailed project timeline for your implementation plan. Adjust the timeline below to fit your needs by choosing the appropriate time frame from the dropdown in cell H9. For example, if you
are doing a week-long camp, you would change the time from weeks to days by choosing "days" from the dropdown. Describe each activity necessary for project planning and implementation in the
"Activity" column, and the person responsible in the column to the right. Indicate when each activity will take place by placing an "X" in the appropriate day, week or month.
Approximate Implementation Period (auto-fills based off of start/end date on Project Classification page):
Months:
Weeks:
Do you want to measure your timeline in

days, weeks or months? Your answer to this
question will populate the timeline headings
below.
Example
Days:
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 1 Month 2
Day, Weeks or Months (headings change automatically according to designation above)
Activity
Person(s) Responsible
Pick up materials from the regional capital
Organization president
Form PC-2105
Additional:

5. Monitoring and Evaluation
Directions
First, provide information for the global Peace Corps small grants indicators. Then, use the table below to list indicators for each of your objectives. For VAST, SPA, ECPA and FTF, there are also a pre-determined set of indicators
which are outlined later in this application. Please be sure to incorporate at least one of the pre-determined program indicators into this section of your project plan.
Capacity Development
Men, 25 and older
Women, 25 and
older
Men, 15-24
Women, 15-24
Boys, 14 and
under
Girls, 14 and
under
Men, 15-24
Women, 15-24
Boys, 14 and
under
Girls, 14 and
under
# of individuals who will have increased capacity due

to this small grant
# service providers who will have increased capacity
due to this small grant
# of community organizations and/or associations
that will have increased capacity due to this small
grant
Organizations
New Technology & Practices

Men, 25 and older
Women, 25 and
older
# of individuals who have applied new technologies

and/or practices as a result of this grant
# of new technologies and/or practices that will have
been adopted as a result of this small grant
Technologies
Practices
Form PC-2105
Objective
EXAMPLE
1
Who
When
How will you measure that the

objective is achieved? Outline your
specific targets (i.e., output and
outcome indicators)
Who will collect the information to

measure success against the
indicator?
When and how often will the

information be collected? What datacollection tools will be used?
1. # individuals trained on the health

Volunteer and counterpart/community
benefits of using improved cookstoves; group
2. # of individuals trained on the
construction and maintenance of
improved cookstoves; 3. # of cookstoves
(new or rehabilitated) purchased or
constructed for households or institutions
(e.g. health clinics, schools) with
assistance of Volunteers or partners
NOTE: Please limit the text to

20 words or less in the blue
"Indicators", "Who", and
"When" boxes.
Weekly assessments of progress will be Community members will use

documented by observation and noting improved cookstoves, water, and
progress in a schedule/calendar.
sanitation to reduce infectious
diseases and improve
environmental health
GOAL
Cookstoves: By the end of XXXX, X# households or

institutions will adopt efficient low-fuel emission cook
stoves to safeguard the health of their
children and families.
Indicator(s)
GOAL 1
1.2
1.3
1.4
2.1
GOAL 2
2.2
2.3
2.4
3.1
GOAL 3
3.2
3.3
3.4
Form PC-2105

6. Do No Harm
Directions
In the design of any project, Volunteers and their community organizations should explore potential intended and unintended consequences of the proposed
interventions. This should consider the environmental, social, economic, and political aspects of project implementation. In designing projects, Volunteers should
investigate potential outcomes of the program in order to minimize negative outcomes. This is a participatory process and includes all stakeholders. The exercise
itself may be helpful in project design as it may identify areas of intervention needed to provide an enabling environment for the success of a Peace Corps project.
1) Please report on the results of your "do no

harm" discussions. Did you find that there were
consequences you hadn't thought about?
General
Environmental
Mitigation
2) If the proposed project is not solely a

training project (i.e., if it involves construction,
agricultural or reforestation activities,
installation of large equipment, etc.), please
discuss possible negative environmental
impacts with your community. What are
potential negative environmental impacts of the
project activities?
3) For each of the potential negative impacts

described in questions 1 and 2, please describe
the measures the community will adopt in order
to monitor and mitigate against potentially
harmful effects.
Form PC-2105

7. Detailed Budget (local currency)
Fill in the Project Information section at the top of this sheet. Please make sure to enter in the exchange rate. If you are not sure of the exact exchange rate, please enter your best estimate of the anticipated exchange rate for the dates of your project. If you
would like to enter amounts directly in U.S. dollars, leave the exchange rate at $1.
As you complete this Detailed Budget, the summary budget below and the budget on the Project Classification page will automatically fill in.
Enter a line for each expected cost the community will incur in carrying out the project. You should enter amounts in local currency. If you are filling out the form electronically, fill out all of the blue cells on each line. For the budget category, please select from
one of the seven options in the dropdown list. The total cost will fill in automatically by formula. For each item, the total cost should be split between grant amount, community contribution, and third-party contribution based on the proposed funding source for
the cost.
If you need additional rows, there are over 100 additional lines that are "hidden" at the bottom of the worksheet. Unhide the rows by following the instructions at the bottom of the sheet.
Directions
Project Title:
Project Information
Project Number:
Community Group:
APCD/Program
Manager:
Requested Project
Amount (in local
currency):
Exchange rate:
$1US =
Project Start Date:

Project Completion Date:
% Community Contribution:
Total Project Cost USD:
Budget Summary
Local Currency $US

- $
- $
- $
- $
- $
- $
- $
Total
- $
Grant Amount
Category
Labor
Equipment
Materials/Supplies
Land/Venue Rental
Travel/Per Diem/Food/Lodging
Materials Transport
Other
- - -
Cash
Local Currency
-
$US
$
$
$
$
$
$
$
$
Form PC-2105
In-Kind
Local Currency
-
$US
$
$
$
$
$
$
$
$
Cash
Third-Party Contribution (if applicable)

In-Kind
Local Currency $US

- $
- $
- $
- $
- $
- $
- $
- $
Local Currency
-
$US
$
$
$
$
$
$
$
$
Grant Amount
Detailed Budget
Line #
1
2
3
Item Description
Budget Category
Unit Cost
Quantity
Total Cost
Cash
0.00
0.00
0.00
0.00
4
5
6
7
8
9
10
11
12
13
14
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Form PC-2105
In-Kind
Third-Party Contribution (if

applicable)
Cash
In-Kind
42
43
44
45
46
47
48
49
50
51
52
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
n/a
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total
n/a
n/a
Form PC-2105
n/a
0.00
0.00
0.00
0.00
0.00
0.00

Grant Type Selection Menu
Directions
Each funding source at Peace Corps has specific application requirements. Select the funding source through
which your project will be funded below to provide the information required by that program.
Please note that not all funding sources are available at every post. If you are unsure of which programs are
available in your country, please consult with post staff.
PCPP
SPA
Other
USAID
VAST
ECPA
FTF
Peace Corps Partnership Program (PCPP): Funded through donations from family,
friends and other donors in the United States. Available in every PC country.
Small Project Assistance (SPA) Program: Funded by USAID. Project activities must
fit within specific Program Elements. Please consult with post staff if you are
unsure which program elements your post has received funds in.
A few Peace Corps posts have arranged for country-specific grant programs funded
by USAID. Indicators for these programs will appear on the same page as the SPA
indicators.
Volunteer Activities Support and Training (VAST): Funded by the President's

Emergency Plan For AIDS Relief (PEPFAR). Projects must contribute to the
prevention of HIV or the mitigation of the impacts of the epidemic.
Energy Climate Partnership of the Americas (ECPA): Funded through an agreement

with the U.S. Department of State. Projects must focus on the environment.
Feed the Future (FtF): Funded by USAID. Projects must strategically respond to
food insecurity vulnerabilities. WAFSP is a regional partnership in West African
countries.
Form PC-2105
Enter Street Address if e-mail is not available

Relationship to
Volunteer
Title
First Name
Last Name
E-Mail
Street Address
Form PC-2105
City
State
Zip Code
Form PC-2105

Small Project Assistance (SPA) Indicators and Environmental Review Forms
All SPA projects must complete an environmental review and provide anticipated indicator data. The
Directions sections below explain what is required for each section.
Indicators
Environmental
Review
ALL applicants must complete this section.
For grant projects involving 1) water/sanitation; 2)

agriculture such as agroforestry and community gardens,
and 3) environment such as natural resource
management, Volunteers must complete and submit an
environmental screening form to the grant review
committee.
Form PC-2105
Peace Corps Small Grant Completion Report

Peace Corps Small Grants Application
SPA Indicators
These data will be transmitted to Peace Corps/Washington to be used for internal Peace Corps reporting and for inclusion in the SPA annual report submitted to USAID/Washington. Information may also be shared with the in-country USAID Mission.
Directions: Choose the Program Element that the project is being funded under from the drop-down list below. Once you choose the Program Element, the indicators for that Program Element will appear. Please fill in information for the indicators relevant to your
project.
Country:
Program Element:
Example:
# of individuals who received a benefit from the project
12
Men 25 and
older
15
Women 25
and older
PC-2105
Men 15-24
10
Women 15-24
Boys 14 and
under
Girls 14 and
under
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
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PC-2105
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Main Menu
SPA Menu
Instructions
Instructions
Peace Corps Small Grants App
SPA ENVIRONMENTAL REVIEW & ASSESSMENT C
Project
Project Classification
Classification
Project Description
Goals & Objectives
Timeline
Timeline
Indicators
For grant projects involving 1) water/sanitation; 2) agriculture such as a

3) environment such as natural resource management, Volunteers mu
screening form to the grant review committee. The grant review comm
form is taken into consideration and given significant weight. The Volu
if any, measures must be taken to mitigate and monitor the environme
Monitoring & Evaluation

Do No Harm
Detailed Budget
Grant
Grant Type
Type Selection
Selection
The purpose of this Environmental Review and Assessment Checklist

proposed action (scope of work) encompasses the potential for environ
determine the scope and extent of additional environmental evaluation
fulfill federal U.S. environmental requirements. The ER Checklist is int
Corps personnel who submit project proposals and the grant selection
consequences are taken into account before making an award for a pr
consequences checklist will assist in determining the potential environm
PCPP
PCPP
SPA and other USAID
VAST
VAST
ECPA
ECPA
FTF
FTF
Signature Forms
Liability
Liability Form
Form
Include cost information on any environmental mitigation and monitorin

Appropriate environmental mitigation and monitoring is considered an
activity.
Please provide the following information. This information will assist th

environmental impact determination on the proposed activity.
Date:
Volunteer Name:
Project
Project Agreement
Agreement
Press Authorization
Location:
Attach a location map as well as site photos in color if possible
End
Project/Activity
Description:
Project/Activity
Description:
Provide sufficient description and details for environmental impact ana

Name of Project/
Activity:
Type of
Project/Activity:
Baseline
Environmental
Conditions:
Provide site specific environmental conditions. Plant and anim

condition, human population characteristics, land use, soil, ec
Describe existing environment at the proposed project site re
impact. Include maps and photos as necessary. Use addition
A. CHECKLIST FOR ENVIRONMENTAL CONSEQUENCES: Check

(M), No (N) or Beneficial (B). Briefly explain Y, M and B checks in
response does not necessarily indicate a significant effect, but ra
consideration.
1. Earth Resources
a. grading trenching, or excavation in cubic meters or hectare
b. geologic hazards (faults, landslides, liquefaction, un-engineered fill,
c. contaminated soils or ground water on the site
d. offsite overburden/waste disposal or borrow pits required in cubic m
e. loss of high-quality farmlands in hectares
2. Agricultural and Agrochemical
a. impacts of inputs such as seeds and fertilizers
b. impact of production process on human health and environment
c. other adverse impacts
3. Industries
a. impacts of run-off and run-on water

b. impact of farming such as intensification or extensification
c. impact of other factors
4. Air Quality
a. substantial increase in onsite air pollutant emissions (construction/o
b. violation of applicable air pollutant emissions or ambient concentrati
c. substantial increase in vehicle traffic during construction or operation
d. demolition or blasting for construction
e. substantial increase in odor during construction or operation
f. substantial alteration of microclimate
5. Water Resources and Quality

a. river, stream or lake onsite or within 30 meters of construction
b. withdrawals from or discharges to surface or ground water
c. excavation or placing of fill, removing gravel from, a river, stream or
d. onsite storage of liquid fuels or hazardous materials in bulk quantitie
6. Cultural Resources
a. prehistoric, historic, or paleontological resources within 30 meters o
b. site/facility with unique cultural or ethnic values
7. Biological Resources
a. vegetation removal or construction in wetlands or riparian areas in h
b. use of pesticides/rodenticides, insecticides, or herbicides in hectare
c. Construction in or adjacent to a designated wildlife refuge
8. Planning and Land Use

a. potential conflict with adjacent land uses
b. non-compliance with existing codes, plans, permits or design factors
c. construction in national park or designated recreational area
d. create substantially annoying source of light or glare
e. relocation of >10 individuals for +6 months
f. interrupt necessary utility or municipal service > 10 individuals for +6
g. substantial loss of inefficient use of mineral or non-renewable resou
h. increase existing noise levels >5 decibels for +3 months
9. Traffic, Transportation and Circulation

a. increase vehicle trips >20% or cause substantial congestion
b. design features cause or contribute to safety hazards
c. inadequate access or emergency access for anticipated volume of p
10. Hazards
a. substantially increase risk of fire, explosion, or hazardous chemical
b. bulk quantities of hazardous materials or fuels stored on site +3 mon

c. create or substantially contribute to human health hazard
11. Other Issues (to be used for categories not captured under1 t
a. substantial adverse impact
b. adverse impact
c. minimal impact
B. EXPLANATION OF ENVIRONMENTAL CONSEQUENCES: explai
C. IDENTIFIED SIGNIFICANT ENVIRONMENTAL IMPACTS (includi

social), if any: (Use ER to identify significant environmental impac
D. PROPOSED MITIGATION MEASURES (if any):
E. PROPOSED MONITORING MEASURES (if any):
ators
Environmental Review
Corps Small Grants Application
REVIEW & ASSESSMENT CHECKLIST (ER Checklist)
nitation; 2) agriculture such as agroforestry and community gardens, and

e management, Volunteers must complete and submit an environmental
mittee. The grant review committee must ensure that information on the
en significant weight. The Volunteer and committee will determine what,
ate and monitor the environmental impact of the project.
ew and Assessment Checklist (ER Checklist) is to determine whether the

passes the potential for environmental pollution or concern and, if so, to
ional environmental evaluation, mitigation, and monitoring necessary to
ments. The ER Checklist is intended to be used by both the Peace
posals and the grant selection committee to ensure that environmental
efore making an award for a proposed activity. The environmental
termining the potential environmental impact of the proposal.
mental mitigation and monitoring in the overall budget proposal.

nd monitoring is considered an integral aspect of the overall project
. This information will assist the grant award committee in making an

the proposed activity.
otos in color if possible
s for environmental impact analysis
conditions. Plant and animal resources, water resource and

cteristics, land use, soil, ecosystem condition, air quality.
he proposed project site relevant to the scope and potential
as necessary. Use additional pages as necessary.
AL CONSEQUENCES: Check appropriate column as Yes (Y), Maybe

explain Y, M and B checks in next Section, "Explanations". A "Y"
ate a significant effect, but rather an issue that requires focused
Enter Y. M. N. or B
in the column
below
ubic meters or hectare

iquefaction, un-engineered fill, etc.)
n the site
borrow pits required in cubic meters or tons
ares
fertilizers
an health and environment
ion or extensification
utant emissions (construction/operation)

missions or ambient concentration standards
during construction or operation
n
onstruction or operation
30 meters of construction
face or ground water
gravel from, a river, stream or lake
dous materials in bulk quantities
l resources within 30 meters of construction

nic values
wetlands or riparian areas in hectare

cides, or herbicides in hectare
nated wildlife refuge
ses
plans, permits or design factors
nated recreational area
of light or glare
onths
l service > 10 individuals for +6 months
mineral or non-renewable resources
bels for +3 months
tion
substantial congestion
o safety hazards
ess for anticipated volume of people or traffic
osion, or hazardous chemical release
s or fuels stored on site +3 months

uman health hazard
gories not captured under1 through 10 above)
AL CONSEQUENCES: explain Y, M and B responses
ONMENTAL IMPACTS (including physical, biological and

nificant environmental impacts)
RES (if any):
URES (if any):
VAST Indicators
HIV Prevention- AB/OP
Male
Ages (in years) <10
10-14
15-17
Female
18-24
25+
<10
10-14
15-17
18-24
25+
# of people reached with

individual and/or small group
level HIV prevention
interventions (P8.1.D)
# of people who received HIV
prevention interventions
primarily focused on
abstinence and/or being
faithful (P8.2.D)
Other Prevention - Most At Risk Populations

# of Most at Risk Populations
(MARPs) reached with
individual and/or small group
level HIV preventive
interventions that are based
on evidence and/or meet the
minimum standards required
(P8.3.D)
Commercial Sex Workers (CSW)

Males
<18
Females
18+
<18
18+
Males
<18
Females
18+
<18
Care - One Care Service (HBHC & HKID)

Males
# of eligible adults and
children who received a
minimum of one care service
(C1.1.D)
<18
Females
18+
<18
Men Who Have Sex

With Men (MSM)
Injecting Drug Users (IDU)
18+
PC-2105
18+
Other Vulnerable Populations
Males
<18
Males
18+
<18
Females
18+
<18
18+
Care - Food and/or Other Nutritional Service (HBHC & HKID)
# of eligible adults and

children who received food
and/or nutritional services
(C5.1.D)
Females
Females
NOT pregnant or
Pregnant and
lactating
Lactating
Males
<18
18+
<18
18+
<18
18+
Human Resources for Health (HRH)

Male
Female
# of community health care

and para-social workers who
successfully completed a
pre-service training (PST)
program (H2.2.D)
# of health care workers
who successfully completed
an in-service training (IST)
program (H2.3.D)
PC-2105

ECPA TARGET OUTPUTS AND OUTCOMES FOR ECPA PROJECT
Please estimate output and outcome targets in the Blue cells

Pink cells need not be estimated prior to project implementation but will be monitored after project completion in the Final Report.
Micro-financing and ongoing support to small businesses and consumers

Outputs
Small business entrepreneurs trained in developing business plans and financing strategies for renewable energy businesses
Small businesses received assistance to access bank loans or private equity

Outcomes
Entrepreneurs with improved business operations as a result of assistance [including starting or expanding their renewable energy small businesses]
Entrepreneurs and consumers successfully accessed bank loans or private equity as a result of assistance
Awareness and knowledge

Municipal, school, and communities awareness and knowledge of climate change, natural resources management, energy efficiency and renewable energy technologies, as well as mitigation and adaptation to climate
change.
Outputs
Community members trained in renewable energy technologies, energy efficiency principles and businesses practices
Community members trained in climate change mitigation and adaptation, including natural resources reforestation
Teachers, outreach workers, and technicians trained in environmental education, nursery management and/or reforestation
Outcomes
Community members demonstrate an increased knowledge of renewable energy technologies and/or energy efficiency principles.
Community members demonstrate an increased knowledge of climate change, disaster preparedness, natural resources management and/or biodiversity conservation,
including reforestation
Teachers, municipal workers, local NGOs, or other outreach workers use new or revised environmental instructional materials and/or lesson plans.resources management
and/or biodiversity conservation, including reforestation
Homes, businesses, or public locations adopt new energy efficiency practices as a result of assistance.
PC-2105
Planning and implementation of projects

.
Outputs
Entrepreneurs and community members supported with project planning, design, management and financing.
Outcomes
Renewable Electrical Energy (new or rehabilitated):
number of
installations
complete
community
members
who use kWhr/yr
at homes
in businesses
in public locations
Improved Cook Stoves or Ovens
Number of cookstoves (new or rehabilitated)

purchased or constructed for households or
institutions (e.g. health clinics, schools) with
assistance of Volunteers or partners
Number of households or institutions with

individuals correctly using and maintaining
improved stoves or ovens, as defined by a
checklist, for at least 50 percent of cooking needs
at homes
in businesses
in public locations
Number of individuals living in households benefitting from new or rehabilitated cookstoves or ovens
Estimated average monthly savings in:

(note: these cells may be left blank
kg of fuel wood (household)

adult F
in project abstract)
adult M
child F
child M
hours gathering fuel
Natural Resources Management / Climate Change Adaptation

Hectares
Forest
production
Watershed
area
Agroforestry
and tree crop
system area
Number of hectares under improved natural resource management as a result of assistance
PC-2105

Feed the Future Indicators and Environmental Review Forms
All Feed the Future projects must complete an environmental review and provide anticipated indicator
Directions data. The sections below explain what is required for each section.
FTF Indicators
All General FTF (non-WAFSP) applicants must complete

this section.
WAFSP Indicators
Environmental
Review form &
Assessment
Checklist
WAFSP applicants must complete this section and do not

need to complete the general FTF indicators.
Required of ALL applicants in order to determine the

level of environmental risk posed by the proposed
project.
PC-2105

Feed the Future Indicators and Environmental Review Forms
Project Title
Food Security Reporting Workaround (FSRW)
Dates
Project
Description
1 October 2012 to 30 September 2013

This Food Security framework is designed to allow Volunteers to report at the level of disaggregation necessary for the Food Security
initiative during FY 2013. (Beginning in FY 2014, VRT 3.0 will support reporting on these indicators in a more natural manner.) All
Volunteers who conduct food security activities should report against one or more objectives from this framework (in addition to any
applicable objectives from their project frameworks) to allow both posts and Peace Corps as a whole to understand and report on our food
security efforts.
Sector
Goal 1
Improved Agriculture Productivity

Increase agriculture sector productivity, food security training, and application of new technologies or management practices
Obj. 1.1
Productivity - New Tech or Mgmt Prac

Number of farmers and others who have applied new technologies or management practices as a result of PC
assistance
Number of MALE farmers and others for the FIRST TIME applying new technologies or management
1.1.a
practices as a result of PC assistance (NEW) (4.5.2-5)
Obj. 1.2
1.1.b
Number of FEMALE farmers and others for the FIRST TIME applying new technologies or
management practices as a result of PC assistance (NEW) (4.5.2-5)
1.1.c
Number of MALE farmers and others CONTINUING to apply new technologies or management
practices as a result of PC assistance (CONTINUING) (4.5.2-5)
1.1.d
Number of FEMALE farmers and others CONTINUING to apply new technologies or management
practices as a result of PC assistance (CONTINUING) (4.5.2-5)
Productivity - Ag prod or food sec trng

Number of individuals who have received PC supported short-term agricultural sector productivity or food security
training
Number of MALE PRODUCERS who have received PC supported short-term agricultural sector
productivity or food security training (4.5.2-7) (PRODUCERS = Farmers, fishers, pastoralists,
1.2.a
ranchers, and other primary sector producers)
Goal 2
1.2.b
Number of FEMALE PRODUCERS who have received PC supported short-term agricultural sector
productivity or food security training (4.5.2-7) (PRODUCERS = Farmers, fishers, pastoralists,
ranchers, and other primary sector producers)
1.2.c
Number of MALE PEOPLE IN GOVERNMENT who have received PC supported short-term

agricultural sector productivity or food security training (4.5.2-7) (PEOPLE IN GOVERNMENT = policy
makers, extension workers)
1.2.d
Number of FEMALE PEOPLE IN GOVERNMENT who have received PC supported short-term

agricultural sector productivity or food security training (4.5.2-7) (PEOPLE IN GOVERNMENT = policy
makers, extension workers)
1.2.e
Number of MALE PRIVATE SECTOR who have received PC supported short-term agricultural sector
productivity or food security training (4.5.2-7) (PRIVATE SECTOR = processors, service providers,
manufacturers)
1.2.f
Number of FEMALE PRIVATE SECTOR who have received PC supported short-term agricultural
sector productivity or food security training (4.5.2-7) (PRIVATE SECTOR = processors, service
providers, manufacturers)
Increased income and employmnt opportnty

Increase income and employment opportunities through access to bank loans and other assistance to food security organizations
Obj. 2.1
Income/Employ - MICRO Enterp Bank Loans

Number of MICRO (1 to 5 FTEs) Enterprises receiving PC assistance to access bank loans
Obj. 2.2
2.1.a
Number of MICRO (1 to 5 FTEs) Enterprises (MALE owned) receiving PC assistance to access bank
loans (4.5.2-30)
2.1.b
Number of MICRO (1 to 5 FTEs) Enterprises (FEMALE owned) receiving PC assistance to access

bank loans (4.5.2-30)
2.1.c
Number of MICRO (1 to 5 FTEs) Enterprises (JOINT owned) receiving PC assistance to access bank
loans (4.5.2-30)
Income/Employ - SMALL Enterp Bank Loans

Number of SMALL (6 to 50 FTEs) Enterprises receiving PC assistance to access bank loans
2.2.a
Number of SMALL (6 to 50 FTEs) Enterprises (MALE owned) receiving PC assistance to access bank
loans (4.5.2-30)
2.2.b
Number of SMALL (6 to 50 FTEs) Enterprises (FEMALE owned) receiving PC assistance to access

bank loans (4.5.2-30)
PC-2105
2.2.c
Obj. 2.3
Number of SMALL (6 to 50 FTEs) Enterprises (JOINT owned) receiving PC assistance to access bank
loans (4.5.2-30)
Income/Employ - MEDIUM Enterp Bank Loans

Number of MEDIUM (51 to 100 FTEs) Enterprises receiving PC assistance to access bank loans
Obj. 2.4
2.3.a
Number of MEDIUM (51 to 100 FTEs) (1 to 5 FTEs) Enterprises (MALE owned) receiving PC
assistance to access bank loans (4.5.2-30)
2.3.b
Number of MEDIUM (51 to 100 FTEs) (1 to 5 FTEs) Enterprises (FEMALE owned) receiving PC
2.3.c
Number of MEDIUM (51 to 100 FTEs) (1 to 5 FTEs) Enterprises (JOINT owned) receiving PC
Income/Employ - PRIVATE ENTERPRIS Assist

Number of food security PRIVATE ENTERPRISES (FOR PROFIT) receiving PC assistance
Obj. 2.5
2.4.a
Number of food security PRIVATE ENTERPRISES (FOR PROFIT) receiving FIRST TIME PC
assistance this year (NEW) (4.5.2-11)
2.4.b
Number of food security PRIVATE ENTERPRISES (FOR PROFIT) receiving PC assistance AGAIN
this year (CONTINUING) (4.5.2-11)
Income/Employ - PRODUCER ORGS Assist

Number of food security PRODUCERS ORGANIZATIONS receiving PC assistance
Obj. 2.6
2.5.a
Number of food security PRODUCER ORGANIZATIONS receiving FIRST TIME PC assistance this
year (NEW) (4.5.2-11)
2.5.b
Number of food security PRODUCER ORGANIZATIONS receiving PC assistance AGAIN this year
(CONTINUING) (4.5.2-11)
Income/Employ - WATER USERS ASSOC Assist

Number of food security WATER USERS ASSOCIATIONS receiving PC assistance
Obj. 2.7
2.6.a
Number of food security WATER USERS ASSOCIATIONS receiving FIRST TIME PC assistance this
year (NEW) (4.5.2-11)
2.6.b
Number of food security WATER USERS ASSOCIATIONS receiving PC assistance AGAIN this year
Income/Employ - WOMEN'S GROUPS Assist

Number of food security WOMEN'S GROUPS receiving PC assistance
Obj. 2.8
2.7.a
Number of food security WOMEN'S GROUPS receiving FIRST TIME PC assistance this year (NEW)
(4.5.2-11)
2.7.b
Number of food security WOMEN'S GROUPS receiving PC assistance AGAIN this year
Income/Employ - TRADE & BUS ASSOC Assist

Number of food security TRADE AND BUSINESS ASSOCIATIONS receiving PC assistance
Obj. 2.9
2.8.a
Number of food security TRADE & BUSINESS ASSOCIATIONS receiving FIRST TIME PC assistance
this year (NEW) (4.5.2-11)
2.8.b
Number of food security TRADE & BUSINESS ASSOCIATIONS receiving PC assistance AGAIN this
year (CONTINUING) (4.5.2-11)
Income/Employ - COMM BASED ORGS Assist

Number of food security COMMUNITY-BASED ORGANIZATIONS (CBOs) receiving PC assistance
Goal 3
2.9.a
Number of food security COMMUNITY-BASED ORGANIZATIONS (CBOs) receiving FIRST TIME PC

assistance this year (NEW) (4.5.2-11)
2.9.b
Number of food security COMMUNITY-BASED ORGANIZATIONS (CBOs) receiving PC assistance

AGAIN this year (CONTINUING) (4.5.2-11)
Improved Nutrition Behavior

Improve nutrition behavior of children through training adults in child health and nutrition and through children's nutrition programs
Obj. 3.1
Nutrition - TRNG in Child HE and Nutrit.

Number of people trained in child health and nutrition through PC-supported health area programs
Obj. 3.2
3.1.a
Number of MALES trained in child health and nutrition through PC-supported health area programs
(3.1.9-1)
3.1.b
Number of FEMALES trained in child health and nutrition through PC-supported health area programs
(3.1.9-1)
Nutrition - Child < 5 Nutrition Programs

Number of children under 5 reached by PC-supported nutrition programs
3.2.a
Number of MALES under 5 reached by PC-supported nutrition programs (3.1.9-11)
3.2.b
Number of FEMALES under 5 reached by PC-supported nutrition programs (3.1.9-11)
PC-2105
Goal 4
YRLY- Increased Investment in ag & nutr.

Year over year, Increase business development services provided to and profitability of agricultural and food-security-related firms and
CSOs
Obj. 4.1
YRLY-Invstmnt - Profitable ag / food sec

Number of firms (excluding farms) or Civil Society Organizations engaged in agricultural and food-security-related
manufacturing and services now operating more profitably (at or above cost) because of PC assistance
Obj. 4.2
4.1.a
Number of more profitable FIRMS engaged in agricultural and food-security-related manufacturing

and services now operating more profitably (at or above cost) because of PC assistance (4.5.2-43)
4.1.b
Number of more profitable CSOs engaged in agricultural and food-security-related manufacturing and
services now operating more profitably (at or above cost) because of PC assistance (4.5.2-43)
YRLY-Invstmnt - MICRO Bus. Dev. Services

Number of Micro (1 to 5 FTEs) Enterprises receiving business development services from PC assisted sources
Obj. 4.3
4.2.a
Number of MICRO (1 to 5 FTEs) Enterprises (AGRICULTURAL PRODUCER - MALE) receiving

business development services from PC assisted sources (4.5.2-37)
4.2.b
Number of MICRO (1 to 5 FTEs) Enterprises (AGRICULTURAL PRODUCER - FEMALE) receiving

4.2.c
Number of MICRO (1 to 5 FTEs) Enterprises (AGRICULTURAL PRODUCER - JOINT) receiving

4.2.d
Number of MICRO (1 to 5 FTEs) Enterprises (INPUT SUPPLIER - MALE) receiving business

development services from PC assisted sources (4.5.2-37)
4.2.e
Number of MICRO (1 to 5 FTEs) Enterprises (INPUT SUPPLIER - FEMALE) receiving business

4.2.f
Number of MICRO (1 to 5 FTEs) Enterprises (INPUT SUPPLIER - JOINT) receiving business

4.2.g
Number of MICRO (1 to 5 FTEs) Enterprises (TRADER - MALE) receiving business development

services from PC assisted sources (4.5.2-37)
4.2.h
Number of MICRO (1 to 5 FTEs) Enterprises (TRADER - FEMALE) receiving business development

4.2.i
Number of MICRO (1 to 5 FTEs) Enterprises (TRADER - JOINT) receiving business development

4.2.j
Number of MICRO (1 to 5 FTEs) Enterprises (OUTPUT PROCESSORS - MALE) receiving business

4.2.k
Number of MICRO (1 to 5 FTEs) Enterprises (OUTPUT PROCESSORS - FEMALE) receiving

4.2.l
Number of MICRO (1 to 5 FTEs) Enterprises (OUTPUT PROCESSORS - JOINT) receiving business

4.2.m
Number of MICRO (1 to 5 FTEs) Enterprises (NON-AGRICULTURE - MALE) receiving business

4.2.n
Number of MICRO (1 to 5 FTEs) Enterprises (NON-AGRICULTURE - FEMALE) receiving business

4.2.o
Number of MICRO (1 to 5 FTEs) Enterprises (NON-AGRICULTURE - JOINT) receiving business

4.2.p
Number of MICRO (1 to 5 FTEs) Enterprises (OTHER - MALE) receiving business development

4.2.q
Number of MICRO (1 to 5 FTEs) Enterprises (OTHER - FEMALE) receiving business development

4.2.r
Number of MICRO (1 to 5 FTEs) Enterprises (OTHER - JOINT) receiving business development

YRLY-Invstmnt - SMALL Bus. Dev. Services

Number of Small (6 to 50 FTEs) Enterprises receiving business development services from PC assisted sources
4.3.a
Number of SMALL (6 to 50 FTEs) Enterprises (AGRICULTURAL PRODUCER - MALE) receiving

4.3.b
Number of SMALL (6 to 50 FTEs) Enterprises (AGRICULTURAL PRODUCER - FEMALE) receiving

4.3.c
Number of SMALL (6 to 50 FTEs) Enterprises (AGRICULTURAL PRODUCER - JOINT) receiving

4.3.d
Number of SMALL (6 to 50 FTEs) Enterprises (INPUT SUPPLIER - MALE) receiving business

4.3.e
Number of SMALL (6 to 50 FTEs) Enterprises (INPUT SUPPLIER - FEMALE) receiving business

PC-2105
Obj. 4.4
4.3.f
Number of SMALL (6 to 50 FTEs) Enterprises (INPUT SUPPLIER - JOINT) receiving business

4.3.g
Number of SMALL (6 to 50 FTEs) Enterprises (TRADER - MALE) receiving business development

4.3.h
Number of SMALL (6 to 50 FTEs) Enterprises (TRADER - FEMALE) receiving business development

4.3.i
Number of SMALL (6 to 50 FTEs) Enterprises (TRADER - JOINT) receiving business development

4.3.j
Number of SMALL (6 to 50 FTEs) Enterprises (OUTPUT PROCESSORS - MALE) receiving business

4.3.k
Number of SMALL (6 to 50 FTEs) Enterprises (OUTPUT PROCESSORS - FEMALE) receiving

4.3.l
Number of SMALL (6 to 50 FTEs) Enterprises (OUTPUT PROCESSORS - JOINT) receiving business

4.3.m
Number of SMALL (6 to 50 FTEs) Enterprises (NON-AGRICULTURE - MALE) receiving business

4.3.n
Number of SMALL (6 to 50 FTEs) Enterprises (NON-AGRICULTURE - FEMALE) receiving business

4.3.o
Number of SMALL (6 to 50 FTEs) Enterprises (NON-AGRICULTURE - JOINT) receiving business

4.3.p
Number of SMALL (6 to 50 FTEs) Enterprises (OTHER - MALE) receiving business development

4.3.q
Number of SMALL (6 to 50 FTEs) Enterprises (OTHER - FEMALE) receiving business development

4.3.r
Number of SMALL (6 to 50 FTEs) Enterprises (OTHER - JOINT) receiving business development

YRLY-Invstmnt - MEDIUM Bus. Dev. Service

Number of Medium (51 to 100 FTEs) Enterprises receiving business development services from PC assisted
sources
Number of MEDIUM (51 to 100 FTEs) Enterprises (AGRICULTURAL PRODUCER - MALE) receiving
4.4.a
4.4.b
Number of MEDIUM (51 to 100 FTEs) Enterprises (AGRICULTURAL PRODUCER - FEMALE)

receiving business development services from PC assisted sources (4.5.2-37)
4.4.c
Number of MEDIUM (51 to 100 FTEs) Enterprises (AGRICULTURAL PRODUCER - JOINT) receiving
4.4.d
Number of MEDIUM (51 to 100 FTEs) Enterprises (INPUT SUPPLIER - MALE) receiving business
4.4.e
Number of MEDIUM (51 to 100 FTEs) Enterprises (INPUT SUPPLIER - FEMALE) receiving business
4.4.f
Number of MEDIUM (51 to 100 FTEs) Enterprises (INPUT SUPPLIER - JOINT) receiving business
4.4.g
Number of MEDIUM (51 to 100 FTEs) Enterprises (TRADER - MALE) receiving business
4.4.h
Number of MEDIUM (51 to 100 FTEs) Enterprises (TRADER - FEMALE) receiving business
4.4.i
Number of MEDIUM (51 to 100 FTEs) Enterprises (TRADER - JOINT) receiving business
4.4.j
Number of MEDIUM (51 to 100 FTEs) Enterprises (OUTPUT PROCESSORS - MALE) receiving
4.4.k
Number of MEDIUM (51 to 100 FTEs) Enterprises (OUTPUT PROCESSORS - FEMALE) receiving
4.4.l
Number of MEDIUM (51 to 100 FTEs) Enterprises (OUTPUT PROCESSORS - JOINT) receiving
4.4.m
Number of MEDIUM (51 to 100 FTEs) Enterprises (NON-AGRICULTURE - MALE) receiving business
4.4.n
Number of MEDIUM (51 to 100 FTEs) Enterprises (NON-AGRICULTURE - FEMALE) receiving

4.4.o
Number of MEDIUM (51 to 100 FTEs) Enterprises (NON-AGRICULTURE - JOINT) receiving business
4.4.p
Number of MEDIUM (51 to 100 FTEs) Enterprises (OTHER - MALE) receiving business development
4.4.q
Number of MEDIUM (51 to 100 FTEs) Enterprises (OTHER - FEMALE) receiving business
PC-2105
4.4.r
Number of MEDIUM (51 to 100 FTEs) Enterprises (OTHER - JOINT) receiving business development
PC-2105

WAFSP Indicator Targets
Directions
Goal of the
WAFSP
Please estimate the indicator results you will be accomplishing and fill in these targets for the indicators relevant to the project in the
blue columns on the right
Key Objectives of the

WAFSP
Ind. codes
4.5.2-5
Indicator Title
Number of farmers and others who have

applied new technologies or management
practices as a result of USG assistance
Disaggregation of the indicator
New or
Continuing
Female
Producers
4.5.2-7
Type of
Number of individuals who have received
individual
USG supported short-term agricultural sector
productivity or food security training
Sex
INCREASE FOOD SECURITY IN THE COMMUNITIES WHERE PCVs WORK IN WEST AFRICA
Continuing
Male
Sex
1. Increase availability
of healthy foods,
especially for women
and children
New
4.5.2-11
Number of food security private enterprises

(for profit), producers organizations, water
users associations, women's groups, trade
and business associations, and communitybased organizations (CBOs) receiving USG
assistance
Size of
MSME
Number of MSMEs, including farmers,
receiving USG assistance to access loans
2. Increase
accessibility of healthy
foods by decreasing
poverty and increasing
incomes
People in Private
Sector Firms
People in Civil Society
Male
Female
Private Enterprises
Producer
Organizations
Water Users
Type of
Associations
organization
Women's Groups
Trade & Business
Assoc.
CBOS
New or
Continuing
4.5.2-30
People in Government
New
Continuing
Micro Enterprise
Small Enterprise
Medium Enterprise
Male owner
Sex of owner Female owner

Joint ownership
PC-2105
Value of the
indicator
(number)
INCREASE FOOD SECURITY IN THE COMMUNITIES
2. Increase
accessibility of healthy
foods by decreasing
poverty and increasing
incomes
4.5.2-37
Number of MSMEs, including farmers,

receiving business development services
from USG assisted sources
4.5.2-43
Number of firms (excluding farms) or CSOs

engaged in agricultural and food-securityrelated manufacturing and services now
operating more profitably (at or above cost)
because of USG assistance
3.1.9-1
3. Improve utilization of
available food stuffs to
improve nutritional status
of women and children
Micro Enterprise
Small Enterprise
Medium Enterprise
Agricultural Producer
Input Supplier
Trader
Type of
MSME
Output Processors
Non-Agriculture
Other
Male owner
Sex of owner Female owner
Joint ownership
Size of
MSME
Custom indicat.
3.1.9-15
Number of people trained in child health and

nutrition through USG-supported health area
programs
Number of people trained in maternal health

and nutrition through USG-supported health
area programs
Number of children under 5 reached by USGsupported nutrition programs
# of Firms
# of Civil Society Organizations
M
F
M
F
M
F
PC-2105

WAFSP Indicator Targets
Indicator narrative
(write one paragraph on the story/activities behind the
figures by responding to the questions in brackets)
(What types of technologies/management practices were

applied? How many people applied what?)
(What were the topics of the trainings? How many individuals

were trained per topic?)
(What types of assistance were received per type of

organization? Provide names and location of organizations
assisted)
(What types of assistance were received? What types of loans

were accessed (cash/in-kind, formal/informal)?)
PC-2105
(What types of business development services were received

per type of MSME? Provide names of MSMEs assisted)
(Describe assistance provided, and how profitability was

calculated)


(Briefly describe the nutrition program)
PC-2105
Peace Corps Small Grants Application

FTF ENVIRONMENTAL REVIEW & ASSESSMENT CHECKLIST (ER Checklist)
For grant projects involving 1) water/sanitation; 2) agriculture such as agroforestry and community gardens, and 3)
environment such as natural resource management, Volunteers must complete and submit an environmental
screening form to the grant review committee. The grant review committee must ensure that information on the
form is taken into consideration and given significant weight. The Volunteer and committee will determine what, if
any, measures must be taken to mitigate and monitor the environmental impact of the project.
The purpose of this Environmental Review and Assessment Checklist (ER Checklist) is to determine whether the
proposed action (scope of work) encompasses the potential for environmental pollution or concern and, if so, to
determine the scope and extent of additional environmental evaluation, mitigation, and monitoring necessary to fulfill
federal U.S. environmental requirements. The ER Checklist is intended to be used by both the Peace Corps
personnel who submit project proposals and the grant selection committee to ensure that environmental
consequences are taken into account before making an award for a proposed activity. The environmental
consequences checklist will assist in determining the potential environmental impact of the proposal.
Include cost information on any environmental mitigation and monitoring in the overall budget proposal. Appropriate
environmental mitigation and monitoring is considered an integral aspect of the overall project activity.
Please provide the following information. This information will assist the grant award committee in making an
environmental impact determination on the proposed activity.
Date:
Volunteer Name:
Location:
Attach a location map as well as site photos in color if possible
Project/Activity
Description:
Provide sufficient description and details for environmental impact analysis

Name of Project/
Activity:
PC-2105
Type of
Project/Activity:
Baseline
Environmental
Conditions:
Provide site specific environmental conditions. Plant and animal resources, water resource and
condition, human population characteristics, land use, soil, ecosystem condition, air quality. Describe
existing environment at the proposed project site relevant to the scope and potential impact. Include
maps and photos as necessary. Use additional pages as necessary.
A. CHECKLIST FOR ENVIRONMENTAL CONSEQUENCES: Check appropriate column as Yes (Y), Maybe (M),
No (N) or Beneficial (B). Briefly explain Y, M and B checks in next Section, "Explanations". A "Y" response
does not necessarily indicate a significant effect, but rather an issue that requires focused consideration.
Enter Y. M. N. or B
in the column
below
1. Earth Resources
a. grading trenching, or excavation in cubic meters or hectare
b. geologic hazards (faults, landslides, liquefaction, un-engineered fill, etc.)
c. contaminated soils or ground water on the site
d. offsite overburden/waste disposal or borrow pits required in cubic meters or tons
e. loss of high-quality farmlands in hectares
2. Agricultural and Agrochemical
a. impacts of inputs such as seeds and fertilizers
b. impact of production process on human health and environment
c. other adverse impacts
3. Industries
a. impacts of run-off and run-on water
b. impact of farming such as intensification or extensification
c. impact of other factors
4. Air Quality
a. substantial increase in onsite air pollutant emissions (construction/operation)
b. violation of applicable air pollutant emissions or ambient concentration standards
c. substantial increase in vehicle traffic during construction or operation
d. demolition or blasting for construction
PC-2105
e. substantial increase in odor during construction or operation

f. substantial alteration of microclimate
5. Water Resources and Quality
a. river, stream or lake onsite or within 30 meters of construction
b. withdrawals from or discharges to surface or ground water
c. excavation or placing of fill, removing gravel from, a river, stream or lake
d. onsite storage of liquid fuels or hazardous materials in bulk quantities
6. Cultural Resources
a. prehistoric, historic, or paleontological resources within 30 meters of construction
b. site/facility with unique cultural or ethnic values
7. Biological Resources
a. vegetation removal or construction in wetlands or riparian areas in hectare
b. use of pesticides/rodenticides, insecticides, or herbicides in hectare
c. Construction in or adjacent to a designated wildlife refuge
8. Planning and Land Use
a. potential conflict with adjacent land uses
b. non-compliance with existing codes, plans, permits or design factors
c. construction in national park or designated recreational area
d. create substantially annoying source of light or glare
e. relocation of >10 individuals for +6 months
f. interrupt necessary utility or municipal service > 10 individuals for +6 months
g. substantial loss of inefficient use of mineral or non-renewable resources
h. increase existing noise levels >5 decibels for +3 months
9. Traffic, Transportation and Circulation
a. increase vehicle trips >20% or cause substantial congestion
b. design features cause or contribute to safety hazards
c. inadequate access or emergency access for anticipated volume of people or traffic
10. Hazards
a. substantially increase risk of fire, explosion, or hazardous chemical release
b. bulk quantities of hazardous materials or fuels stored on site +3 months
c. create or substantially contribute to human health hazard
11. Other Issues (to be used for categories not captured under1 through 10 above)
a. substantial adverse impact
b. adverse impact
c. minimal impact
B. EXPLANATION OF ENVIRONMENTAL CONSEQUENCES: explain Y, M and B responses
PC-2105
C. IDENTIFIED SIGNIFICANT ENVIRONMENTAL IMPACTS (including physical, biological and

social), if any: (Use ER to identify significant environmental impacts)
D. PROPOSED MITIGATION MEASURES (if any):
E. PROPOSED MONITORING MEASURES (if any):
PC-2105

Signature Forms
Directions
Once you have completed all other sections of this application, please print out the following pages, obtain the required
signatures, and return hard copies to post.
1. Liability Form
Fill out the form according to who will be responsible for the project funds: the
Peace Corps Volunteer or the Community. Once complete, print the form.
2. Project Agreement
Must be printed for all projects.
3. Press Authorization
Must be printed for all projects.
PC-2105

Peace Corps Volunteer Consent and Liability Signature Form
Directions
If you will be accepting the project funds, print out this form, obtain the necessary signatures, and return
a hard copy to post. If the project funds will be transferred to the community organization, please ensure
the community member accepting the funds signs this document.
Project Title:
Project Number:
Volunteer Name:
Peace Corps Country:
Community Partner:
YOU MUST ENTER A COMMUNITY

GROUP NAME ON THE PROJECT
CLASSIFICATION SCREEN
Funding Source:
Grant Amount (USD):
Authorized
Representative of the
Community Partner:
$0.00
By signing below, the Authorized Representative on behalf of the Community Partner and the Peace Corps Volunteer agree
to the following:
TERMS AND CONDITIONS FOR THE COMMUNITY PARTNER AND PEACE CORPS VOLUNTEER
1. Project funds may to be used only for reasonable costs of the Project.
2. The Community Partner and Peace Corps Volunteer are responsible for managing these funds in accordance with the
guidelines applicable to the above referenced funding source and accounting for the use of Project funds.
3. The Community Partner and Peace Corps Volunteer are responsible for obtaining, keeping, recording in the Small Grant
Project Log and submitting to the Peace Corps all original invoices, receipts, or other documentation for all purchases or
other expenditures of Project funds. For all purchases made without the Volunteer present, the Community Partner must
notify the Volunteer, obtain a signed, dated, and witnessed receipt, and record the expenditure in the Small Grant Project
Log.
4. The Community Partner and Peace Corps Volunteer are responsible for returning any unused funds that remain within 30
days of the completion of the Project.
5. Except as agreed to otherwise by the Peace Corps, the Community Partner and Peace Corps Volunteer are liable for any
Project funds disbursed to them that cannot be accounted for or were spent on non-approved costs, lost, or stolen.
6. The Community Partner and Peace Corps Volunteer acknowledge that (a) there will be no additional funding beyond the
Funding Amount above and (b) if this is a Peace Corps Partnership Program (PCPP) project, that funding is not guaranteed.
7. The Community Partner is responsible for obtaining the 25 percent community contribution to the project.
8. The Volunteer and the Peace Corps are not responsible for any activities, expenditures, or liabilities incurred after the
project is closed.
Authorized Representative Name

(Print)
Signature
Date
NOTE: Signatures continue on Page 2

PC-2105
ADDITIONAL TERMS AND CONDITIONS FOR THE PEACE CORPS VOLUNTEER

1. I will work closely with my Community Partner to establish a funds-management system.
2. If funds are transferred to the same bank account through which I receive my Volunteer living allowance, I will take all
necessary measures to ensure that grant funds are not commingled with my living allowance.
3. I will strictly account for all grant funds and will not use any grant funds for personal use.
4. Any Project funds disbursed to the Peace Corps Volunteer that cannot be accounted for or were spent on non-approved
costs, lost, or stolen may be deducted from my readjustment allowance as a debt owed to the Peace Corps (Pursuant to MS
223).
5. The Peace Corps may contact the referrals I provided.
Peace Corps Volunteer Name

(Print)
Peace Corps Volunteer Signature
Date
PEACE CORPS APPROVAL

have reviewed this Application and certify that it meets the requirements of the applicable funding source, and that it is wellII have
reviewed
planned, accurately budgeted, and the Peace Corps Volunteer and Community Partner possess the technical skills to
this
successfully complete the project within the timeframe of the Volunteers term of service.
Application
and certify
that it meets
the
requirement
s of the
Country Director (Print)
Country Director Signature
Date
applicable
funding
source, and
that it is
wellplanned,
accurately
budgeted,
and the
Peace
Corps
Volunteer
and
Community
Partner
possess the
technical
skills to
successfully
complete
the project
within the
timeframe
of the
Volunteers
term of
service.
PC-2105

Project Agreement
PEACE CORPS/
PROJECT AGREEMENT
Community Organization:
Project Number:
Volunteer Name:
COS Date:
Implementation Dates:
Start Date:
Projected Completion Date:
Budget:
Local Contribution
$0.00
= Local
Currency @
1.00
0.00
Grant Amount
$0.00
= Local
Currency @
1.00
0.00
Third Party
Contribution
$0.00
= Local
Currency @
1.00
0.00
Total Project Cost
$0.00
= Local
Currency @
1.00
0.00
0%
Obligation Number
IN WITNESS WHEREOF, the community organization named above, the Peace Corps Volunteer, and Peace Corps, pursuant to the terms
and conditions of
By signing this Project Agreement, the community organization and Volunteer agrees to use project funds to support only the activities and
goals described in this project application, and in accordance with the proposed budget. Equipment and goods purchased using funds
awarded will be used to support the objectives of the project and in accordance with the project Application.
Organization Official Signature
Peace Corps Country Director Signature

(Date)
(Date)
APCD (If required by post)
Peace Corps Volunteer Signature

(Date)
(Date)
PC-2105

Press Authorization Form
Please fill out the Press Authorization form, so PC/headquarters staff may publicize your project. For PCPP, this will also
allow staff to upload any of your submitted photographs to your project page on the Peace Corps Website
(www.peacecorps.gov/donate). PC/headquarters staff may also contact you to be featured in articles about your project
and PC experiences.
Project Photo Details: For those submitting a PCPP project, PC/headquarters staff can upload Volunteer/Community
photos with each project summary on the donation website. Each project may have one to three photographs associated
with the summary. Pictures of community members, the site of the project, and before pictures are generally the most
compelling for donors. Please use at least the standard quality of pictureno less than 72 pixels/inch. (PC/headquarters
staff may need to crop images.) You must fill out this form for your pictures to be shown on the Peace Corps Website.
I, the undersigned, hereby grant to the Peace Corps a perpetual, worldwide, royalty-free, non-exclusive license to use,
reproduce, or publish for purposes authorized by the Peace Corps Act: my name; the negatives and prints of photographs,
videotapes, and/or other audio or visual recordings of myself; my articles and stories; and any other documents, writings,
statements, recordings, representations, or information I may provide pursuant to and in accordance with the terms of this
Authorization.
In particular, I hereby authorize the Peace Corps to use, reproduce, or publish any or all of the above-listed items and to
make reference to me in connection with these items to promote the Peace Corps using various media and publicity
means, including, but not limited to: websites; books; public service advertising on television and radio stations; television
and radio broadcasts; direct-mail pieces; print advertisements; brochures; flyers; posters; articles; editorials; speeches;
roundtable discussions; radio interviews; and television programs.
I acknowledge that I will receive no compensation from the Peace Corps in consideration of this Authorization or the use of
the above-listed items pursuant to this Authorization.
Volunteer Name
Volunteer Signature
Date
PC-2105
Thank you for completing your small grants application. Please submit this application to
the appropriate staff member at post for project approval.
Return to Grant Selection Menu
Return to Main Menu
Labor
1.3.7, Law Enforcement Restructuring, Reform and Operations
Equipment
2.2.3, Local Government and Decentralization
Materials/Supplies 2.2.4, Anti-Corruption Reforms
Land/Venue Rental 2.3.2, Elections and Political Processes
Travel/Per Diem/Foo 2.4.1, Civic Participation
Materials transport 3.1.1, HIV/AIDS
Other
3.1.3, Malaria
2010 3.1.6, Maternal and Child Health
2011 3.1.7, Family Planning and Reproductive Health
2012 3.1.8, Water Supply and Sanitation
2013 3.1.9, Nutrition
2014 3.2.1, Basic Education
2015 3.2.2, Higher Education
2016 3.3.2, Social Services
3.3.3, Social Assistance
4.2.1, Trade and Investment Enabling Environment
4.2.2, Trade and Investment Capacity
4.3.1, Financial Sector Enabling Environment
4.3.2, Financial Sector Capacity
4.5.1, Agriculture Enabling Environment
4.5.2, Agricultural Sector Productivity
4.6.1, Business Enabling Environment
Days
4.6.2, Private Sector Capacity
Weeks
4.6.3, Workforce Development
Months
4.7.3, Strengthen Microenterprise Productivity
4.8.1, Natural Resources and Biodiversity
4.8.2, Clean Productive Environment
5.2.1, Capacity Building, Preparedness and Planning
5.2.2, Disaster Readiness and Mitigation
6.1.1, Cross Cutting
6.6.6, Mozambique USAID Education Funds
9.9.9, PLACE HOLDER TO END THE LIST
1
3
4
5
6
7
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Albania
Armenia
Azerbaijan
Belize
Benin
Bolivia
Botswana
Bulgaria
Burkina Faso
Cambodia
Cameroon
Cape Verde
China
Colombia
Costa Rica
Dominican Rep
Eastern Carib
Ecuador
El Salvador
Ethiopia
Fiji
The Gambia
Georgia
Ghana
Guatemala
Guinea
Guyana
Honduras
Indonesia
Jamaica
Jordan
Kazakhstan
Kenya
Kyrgyz Republ
Lesotho
Liberia
Macedonia
Madagascar
Malawi
Mali
Mexico
Micronesia an
Moldova
Mongolia
Morocco
Mozambique
Namibia
Nepal
Nicaragua
Niger
Panama
Paraguay
Peru
304
305
314
535
680
511
637
313
686
303
694
655
366
514
515
517
538
518
519
663
411
635
242
641
520
675
504
522
497
532
440
306
615
307
632
669
249
684
614
688
510
401
261
309
378
640
697
367
524
683
525
526
527
EMA
EMA
EMA
IAP
AF
IAP
AF
EMA
AF
EMA
AF
AF
EMA
IAP
IAP
IAP
IAP
IAP
IAP
AF
IAP
AF
EMA
AF
IAP
AF
IAP
IAP
EMA
IAP
EMA
EMA
AF
EMA
AF
AF
EMA
AF
AF
AF
IAP
IAP
EMA
EMA
EMA
AF
AF
EMA
IAP
AF
IAP
IAP
IAP
XX
X
Yes
No
N/A
Agriculture
Small Enterprise Development
Education
Environment
Health
Youth
Small Proje
Peace Corp
Volunteer A
Energy Cli
Feed the F
Global Edu
Philippines
Romania
Rwanda
Samoa
Senegal
Sierra Leone
South Africa
Suriname
Swaziland
Tanzania
Thailand
Togo
Tonga
Turkmenistan
Uganda
Ukraine
Vanuatu
Zambia
492
403
696
491
685
636
674
568
645
621
493
693
421
315
617
343
461
611
EMA
EMA
AF
IAP
AF
AF
AF
IAP
AF
AF
IAP
AF
IAP
EMA
AF
EMA
IAP
AF
SP
PP
VA
EC
FF
GEF
Albania
E/E
Armenia
E/E
Azerbaijan
E/E
Benin
AF
Burkina Faso
AF
Cambodia
Asia
Cameroon
AF
Cape Verde
AF
Colombia
LAC
Costa Rica
LAC
Dominican RepublLAC
Eastern Caribbea LAC
Ecuador
LAC
El Salvador
LAC
Ethiopia
AF
Fiji
ANE
Georgia
E/E
Ghana
AF
Guatemala
IAP
Guinea
AF
Jamaica
LAC
Jordan
ME
Kyrgyz Republic Asia
Liberia
AF
Macedonia
E/E
Madagascar
AF
Malawi
AF
Mali
AF
Mexico
LAC
Micronesia
LAC
Moldova
E/E
Mongolia
Asia
Morocco
ME
Mozambique
AF
Nicaragua
LAC
Panama
LAC
Paraguay
LAC
Peru
LAC
Philippines
Asia
Romania
E/E
Rwanda
AF
Senegal
AF
Sierra Leone
AF
Tanzania
AF
The Gambia
AF
Togo
AF
Turkmenistan
Asia
Uganda
AF
Ukraine
E/E
Vanuatu
ANE
Zambia
AF
Authority: This ECPA Project Agreement is execute

Authority: This SPA Project Agreement is executed
Authority: This VAST Project Agreement is execute
Authority: This FTF Project Agreement is executed
Authority: This PCPP Project Agreement is executed
For SPA
the PAPA referenced above, each acting through its
For VAST
the Memorandum of Understanding referenced abo
For ECPA
the IAA referenced above, each acting through its re
For PCPP
the Manual Section 720 and Manual Section 721, h
For FTF
the PAPA referenced above, each acting through its
Project Agreement is executed pursuant to the Interagency Acquisition Agreement (IAA) between the United States Department of State an
roject Agreement is executed pursuant to the current Small Project Assistance (SPA) IV Participating Agency Program Agreement between
Project Agreement is executed pursuant to the Memorandum of Understanding established between Peace Corps and the PEPFAR initiatit
roject Agreement is executed pursuant to the current Global Food Security Participating Agency Program Agreement between the U.S. Age
Project Agreement is executed purusant to the Peace Corps Manual Section 720 which states that, "Donations to the Partnership Program
above, each acting through its respective duly authorized representative, have caused this SPA Project Agreement to be signed under their
Understanding referenced above, each acting through its respective duly authorized representative, have caused this VAST Project Agreeme
ove, each acting through its respective duly authorized representative, have caused this ECPA Project Agreement to be signed under their r
20 and Manual Section 721, have caused this PCPP Project Agreement to be signed under their respective names and delivered as of this d
above, each acting through its respective duly authorized representative, have caused this FTF Project Agreement to be signed under their
es Department of State and the Peace Corps (PC) signed on August 6, 2010.
ram Agreement between the U.S. Agency for International Development (USAID) and the Peace Corps governing Small Project Assistance
s and the PEPFAR initiatitve.
ent between the U.S. Agency for International Development (USAID) and the Peace Corps (PC) governing Feed the Future Food Security P
the Partnership Program shall be applied exclusively for overseas projects. Donations for projects may be accepted only if they meet the cr
to be signed under their respective names and delivered as of this date and year.
his VAST Project Agreement to be signed under their respective names and delivered as of this date and year.
s and delivered as of this date and year.
Small Project Assistance Funds, signed on September 28, 2012.
he Future Food Security Project Funds, signed on July 28, 2011.
ed only if they meet the criteria set forth in Manual Section 721, Gifts and Contributions to the Peace Corps."

Peace Corps Small Grants Application Form

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Peace Corps Small Grants Application Form

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This form was updated on 4-23-2013

Peace Corps Small Grant Application

Instructions on this Application

To be filled out by post staff

Will automatically populate based on information entered in

HOW TO START A NEW PARAGRAPH IN A CELL:

PRINTING THIS APPLICATION:

Peace Corps Small Grant Application

Project Funding Source:

Community Group Name:

Project Start Date:

Project End Date:

Peace Corps Sector

Names of Other PCVs Involved in Project

Community and Economic

Gender and Development

Water and Sanitation

25 years old and 15 to 24 years

Project Cost Breakdown (in U.S. Dollars)

Third-Party Contribution (if

All Volunteers should reference the

Peace Corps Small Grant Application

1) Please provide a brief summary of the project (up to

2) Describe the background of the community, and

3) How is the community the driving force behind the

4) Briefly describe the desired outcome of the project.

5) Describe the implementation plan that will be used

6) How will the project contribute to building skills and

7) How will the community be able to sustain the

Peace Corps Small Grant Application

Peace Corps Small Grant Application

Do you want to measure your timeline in

Day, Weeks or Months (headings change automatically according to designation above)

Pick up materials from the regional capital

Peace Corps Small Grant Application

# of individuals who will have increased capacity due

New Technology & Practices

# of individuals who have applied new technologies

How will you measure that the

Who will collect the information to

When and how often will the

1. # individuals trained on the health

NOTE: Please limit the text to

Weekly assessments of progress will be Community members will use

Cookstoves: By the end of XXXX, X# households or

Peace Corps Small Grant Application

1) Please report on the results of your "do no

2) If the proposed project is not solely a

3) For each of the potential negative impacts

Peace Corps Small Grant Application

Project Start Date:

Local Currency $US

Third-Party Contribution (if applicable)

Local Currency $US

Third-Party Contribution (if

Peace Corps Small Grant Application

Volunteer Activities Support and Training (VAST): Funded by the President's

Energy Climate Partnership of the Americas (ECPA): Funded through an agreement

Enter Street Address if e-mail is not available

Peace Corps Small Grant Application

Directions sections below explain what is required for each section.

ALL applicants must complete this section.

For grant projects involving 1) water/sanitation; 2)

Peace Corps Small Grant Completion Report

Peace Corps Small Grants App

SPA ENVIRONMENTAL REVIEW & ASSESSMENT C

For grant projects involving 1) water/sanitation; 2) agriculture such as a