ViiV Healthcare
For external use
Positive Action Europe Grant Application & Budget Form
Section 1: How to complete this form
This request for proposal (RFP) has been developed for the 2016 cycle of ViiV Healthcare’s Positive Action Europe programme.
Positive Action Europe aims to support communities impacted by HIV in Europe. Grants will be given to grassroots
programmes that meet one or more of the following criteria:
 Supports HIV-related education, knowledge building and treatment literacy
 Drives peer support and education
 Puts the patient at the centre of services
 Fights stigma and discrimination
 Supports the ageing PLHIV
 Promotes testing and earlier diagnosis
Organisations are asked to restrict their funding request to EUR 25,000.
Please note the guidance around the word limit in Sections 4 and 6, and that applications exceeding this limit may not be
considered.
Countries eligible for submission:
Albania and Kosovo, Austria, Belgium , Bosnia and Herzgovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland , France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Latvia, Lithuania, Macedonia, Malta, Netherlands,
Norway, Poland, Portugal, Romania, Serbia and Montenegro, Slovakia, Slovenia, Spain, Sweden, Switzerland , United Kingdom
Applications must be submitted to [email protected]
Section 2: Eligibility Assessment
This section is designed to serve as a brief exercise to help you determine if your organisation is a good match to receive grant
funding from ViiV Healthcare’s Positive Action Europe Initiative, and to ensure our priorities and objectives are aligned.
1.
Is your organisation a registered non-profit or charity, non-governmental organisation (NGO),
patient organisation (PO) or community-based organisation (CBO)?
Yes
No
2.
Does your organisation focus on HIV/AIDS and directly related issues (at least 75% of activities
and spending)?
Yes
No
3.
Does your organisation focus on supporting people living with HIV or help to raise awareness of
HIV among the general public?
Yes
No
4.
Do people living with HIV and other inadequately served populations serve on the Board of your
organisation?
Yes
No
VIIV/OTH/0009/15 Sept 2015
5.
Does your organisation involve people living with HIV and other inadequately served
populations in the development and implementation of programs and activities?
6.
What percentage of your organisation’s overall income does this grant request represent?
7.
Yes
No
Has the organisation submitted a list of Directors and Officers?
Yes
No
8.
Can you confirm that there are no links to government officials within your organisation?
Yes
No
9.
Have you submitted a separate list of directors, identifying any who are government officials or
healthcare professionals?
Yes
No
10.
Have you attached a link to, or a copy of, your most recent Annual Report?
Yes
No
11.
Is this application duplicative of existing programmes or partnerships?
Yes
No
12.
Please attach or provide evidence of registration of your organisation’s status as an NGO, PO or
CBO
The above assessment provides an indication of the aims of, and what is important to, ViiV Healthcare. If you responded “No”
to several of the questions above, it is likely that your application is not in line with the scope of this request for proposal.
Section 3: Organisation Contact Details
Organisation Name:
Postal Address:
Legal Address:
Contact Person, Title:
Telephone:
Fax:
E-mail:
[Street/PO Box]
[City]
[Province/State]
[Postal Code]
[Country]
[If different from Postal Address]
[Including country code]
Telephone (alternative):
Skype:
Website:
Section 4: Organisation Background
Mission statement:
[Or brief description of overall goal]
Legal status:
Country of registration:
Registered since:
History:
[Charity, Trust, Foundation, etc.]
[Year of registration as legal entity]
[Brief description of the organisation and why it was created]
[Max. 350 words]
Goals & Objectives:
[List of the goals and objectives of your organisation]
[Max. 350 words]
Achievements:
[Successes of the organisation and how they relate to this proposal]
[Max. 250 words]
Population(s) served:
[Describe the groups the organisation is working for and with]
[Max. 250 words]
Involvement of PLHIV:
[Describe how people living with HIV are involved in the organisation]
[Max. 250 words]
Section 5: Financial Summary
Please use your local currency
Annual budget:
Historic budgets:
Secured budget:
Requested amount:
Breakdown of grant by year:
[Budget of the organisation for current year]
[Annual budgets for 2013, 2014, 2015)
[Amount of budget for which funding has been secured]
[Total grant amount limited to EUR25,000]
[If the grant is paid over a number of years, please provide this breakdown]
Section 6: Programme Description and Title (max. 350 words)
Please provide a description of the proposed programme or initiative you seek to implement with ViiV Healthcare grant
funding. Include objectives, activities and timelines and your metrics and evaluation framework.
Programme Title:
Programme Start Date:
Programme Completion Date:
Description of the programme or initiative for which you seek funding:
Monitoring & Evaluation Framework:
What is your proposed monitoring and evaluation system? How will you measure results?
Section 7: Budget
Please use the following table to provide estimated budget for your proposed programme.
Budget Line
Specification
A. Salaries and Fees
Additional questions:
1. Which communities will benefit from successful implementation?
Subtotals
B. Office Space and Related Costs
2. How will outcomes for people living with HIV be measured?
Subtotals
C. Administrative and Other Direct Costs
3. Which partners will be involved in the implementation?
Subtotals
D. Materials/Supplies
4. How you will measure results/success?
Subtotals
E. Workshops/Trainings
Subtotals
F. Travel
Subtotals
G. Fees, insurances, Taxes
Subtotals
H. Other (please specify)
Subtotals
Total amounts
Budget
Amount
(EUR)
Secured
Amount
(EUR)
Requested
Amount
(EUR)