Form 1: VAST Proposal Application

Volunteer Activities, Support and Training (VAST) Program A. Project summary

Country: VAST Project Title: Community Organization: Implementation Period: Volunteer Name (s)

From:

To: COS date:

B. Project Description
HIV/AIDS Program Area Budget Code (choose one): Abstinence, be faithful Other prevention (HVOP) (HVAB) Basic health care & support, Orphans & Vulnerable Children Nutrition (HBHC) (HKID) Organizational Capacity Counseling & Testing (HVCT) Building (OHSS) (Please write one concise statement on the goal of this VAST

C. Project Goal
project.):

D. Project Objectives (Please write out each objective for your project.
All objectives should collectively meet the above goal. Please keep # of objectives to 4 or less.):

1. What methods will you use to evaluate the success of your project? (e.g. focus groups, interviews, observations) Please describe for each objective.

E. Sustainability
questions.):

(Please provide a brief explanation to the following

1. What community-identified priority does this VAST project address? 2. How will this project build skills within the community or local organization? 3. How will the community or local organization be able to sustain the benefits of this project?

F. Do No Harm
questions.):

(Please provide a brief explanation to the following

1. What are the potential negative effects of this project (environmental, social, political, or economic)? 2. For each of the effects listed above, please describe the steps the community or local organization will take to mitigate them.

G. Budget (see attached)

Indicators & Targets:

The below indicators & age breakdowns are what Peace Corps uses for PEPFAR reporting. Your project may address only 1 or2 areas. Please fill out ONLY the relevant indicators and then tally the total.

Abstinence and Being Faithful

AB Indicator # Men (25 & >) # Yout h Boys (1524) # Boy s (<1 5) # Wome n (25 & >) # Yout h Girls (1524) # Girl s (<1 5) Total

# Of people who will receive HIV prevention interventions primarily focused on abstinence and/or being faithful.

Other Prevention
# Of people who will be reached with individual and/or small group level HIV prevention interventions.

Other Prevention - Most At-Risk Populations

# Of MARPs who will receive individual and/or small group level HIV preventive interventions.

Care - One Care Service

Care - One Care Service
# Of eligible adults and children who will receive a minimum of one care service.

# Men (25 & >)

# Yout h Boys (1524)

# Boy s (<1 5)

# Wome n (25 & >)

# Yout h Girls (1524)

# Girl s (<1 5)

Total

Care- Food and/or other Nutritional Service

# Of eligible adults and children who will receive food and/or nutritional services.

Human Resources for Health (HRH)

HSS- Human Resources for Health (HRH) # Men (25 & # Yout h Boys # Boy s (<1 # Wome n (25 & >) # Yout h Girls # Girl s (<1 Total

>)
# Of health care workers who will successfully complete an in-service training program within the reporting period.

(1524)

5)

(1524)

5)

TOTAL:
Total Estimated Beneficiaries to be Reached
# Of individuals and/or service providers who will be assisted or trained by this VAST project

# Men (25 & >)

# Yout h Boys (1524)

# Boy s (<1 5)

# Wome n (25 & >)

# Yout h Girls (1524)

# Girl s (<1 5)

Total

Project Budget: Volunteer Name: Project Title: PROJECT COST BREAKDOWN IN US Dollars Third Community Party Contribution Contributi VAST Category on Funds In Cas In Cash Kind h Kind Labor Equipment Materials/Suppli es Venue Rental Travel/Per Diem Transportation of Materials Other TOTAL Resource Descriptions: Category Description Labor

Third Party Name

TOTAL

Equipment Materials/Sup plies

Venue Rental Travel & Per Diem Transportatio n of Materials Other

Project Budget: Volunteer Name: Project Title: PROJECT COST BREAKDOWN IN US Dollars Third Community Party Contribution Contributi VAST Category on Funds In Cas In Cash Kind h Kind Labor Equipment Materials/Suppli es Venue Rental Travel/Per Diem Transportation of Materials Other TOTAL Resource Descriptions: Category Description Labor

Third Party Name

TOTAL

Equipment

Materials/Sup plies Venue Rental Travel & Per Diem Transportatio n of Materials Other

Form 2: Consent & Liability

VAST - CONSENT AND LIABILITY ACCEPTANCE Peace Corps Volunteer or Community Organization Official/Counterpart (To be filled out and signed before funds are transferred to the Volunteer or Community.) By signing this statement, I agree to accept VAST funds on behalf of the Community Group / Organization listed below, and for the purpose of implementing VAST Project Title __________. I assume responsibility for managing these project funds in accordance with VAST Program guidelines, and for obtaining the necessary original invoices and receipts for all purchases or expenditures made in connection with this VAST Project. At the end of the Project, I will account for the use of these funds by returning all allowable receipts and any remaining cash to the Peace Corps Office. To the extent possible, all purchases and payments drawn against the VAST Project will be made by Electronic Funds Transfer (EFT) or cash ordered through Peace Corps. To decrease my own personal liability, I will work closely with my community or organization to establish a funds management system and/or community or Project bank account and, when possible, utilize bank transfers for major purchases. For any and all purchases or payments made with VAST funds, I will obtain a signed, dated, and witnessed receipt, and record the expenditure in the VAST Project Log. I understand that any loss of VAST funds under my control, due to negligence on my part in not following these stated requirements, may result in me being held accountable to repay all, or a portion, of the VAST funds. I further understand that my liability to the Peace Corps with respect to this Project is limited to the management of funds secured through the VAST Project.

Local Organization Name:

Organization Official Signature: Printed Name/Title: Date: Peace Corps Volunteer Signature: Printed Name: Date:

Post Administrative Officer

Signat ure: Printed

Name: Date:

Form 3: Project Agreement

VAST Project Title: Community Organization: Implementation Period: Volunteer Name Budget Summary: Local Contributio n VAST Amount Total Project USD Local Currency Local Currency Local Currency

From:

To: COS date: Percentage of Project: %

USD USD

% %

HIV/AIDS Program Area Budget Code (choose one): Abstinence, be faithful Other prevention (HVOP) (HVAB) Basic health care & support, Orphans & Vulnerable Children Nutrition (HBHC) (HKID) Organizational Capacity Counseling & Testing (HVCT) Building (OHSS) Authority: IN WITNESS WHEREOF, the COMMUNITY ORGANIZATION listed above and Peace Corps, pursuant to the terms and conditions of the Memorandum of Understanding and Implementing Instrument referenced above, each acting through its respective duly authorized representative, have caused this VAST Project Agreement to be signed in their names and delivered as of this date and year. Signature: Name: Title: Date: Signature: Name: Title: Date:

(Community Organization Official)

(Peace Corps Country Director)

Administrative Unit: Approved for obligation: Fiscal coding: Obligation number: Administrative Officer: Vendor: