Form 1: VAST Proposal Application

Volunteer Activities, Support and Training (VAST) Program

PROJECT PROPOSAL Once Approved, submit to OAR vast@peacecorps.gov subject heading: VAST Proposal

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)

C. Project Goal
project.):

(Please write one concise statement on the goal of this VAST

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

(Please provide a brief explanation to the following questions.):

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

(Please provide a brief explanation to the following questions.):

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

# Men (25 & >)

# Youth Boys (1524)

# Boys (<15 )

# Women (25 & >)

# Youth Girls (1524)

# Girls (<15 )

Total

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 & >)

# Youth Boys (1524)

# Boys (<15 )

# Women (25 & >)

# Youth Girls (1524)

# Girls (<15 )

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 & >) # Youth Boys (1524) # Boys (<15 ) # Women (25 & >) # Youth Girls (1524) # Girls (<15 ) Total

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

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 & >)

# Youth Boys (1524)

# Boys (<15 )

# Women (25 & >)

# Youth Girls (1524)

# Girls (<15 )

Total

Project Budget: Volunteer Name: Project Title: PROJECT COST BREAKDOWN IN US Dollars Third Party Community Contributi Contribution VAST on Category 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 3

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Venue Rental Travel & Per Diem Transportation of Materials Other

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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 5

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Name: Date:

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Form 3: Project Agreement
VAST Project Title: Community Organization: Implementation Period: Volunteer Name Budget Summary: Local Contribution VAST Amount Total Project USD USD USD Local Currency Local Currency Local Currency

From:

To: COS date: Percentage of Project: % % %

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: Administrative Unit: Approved for obligation: Fiscal coding: Obligation number: Administrative Officer: Vendor: Signature: Name: Title: Date:

(Community Organization Official)

(Peace Corps Country Director)

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Form 4: VAST Completion Report
Once completed, please submit to OAR vast@peacecorps.gov Subject heading: VAST Completion Report
When your project is completed, you are required to fill in the following completion report and turn it in to the VAST grants manager with the Project Log and corresponding receipts. Please enter the final numbers for relevant indicators and respond to the narrative questions.

How did the project achieve the goals and objectives? Please state your results per objective.

Please describe any anecdotal evidence/stories from community members that attest to project success.

What worked well during implementation of the project?

What did not work well while implementing the project?

What were the major lessons learned during this project?

Did your project change from the original proposal? If so, how?

Based on your experience, what would you recommend for future projects?

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Abstinence and Being Faithful

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

# Men (25 & >)

# Youth Boys (15-24)

# Boy s (<1 5)

# Wome n (25 & >)

# Youth Girls (1524)

# Girl s (<1 5)

Tot al

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 & >)

# Youth Boys (15-24)

# Boy s (<1 5)

# Wome n (25 & >)

# Youth Girls (1524)

# Girl s (<1 5)

Tot al

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 & >) # Youth Boys # Boy s # Wome n (25 # Youth Girls # Girl s Tot al

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(15-24)
# Of health care workers who will successfully complete an in-service training program within the reporting period.

(<1 5)

& >)

(1524)

(<1 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 & >)

# Youth Boys (15-24)

# Boy s (<1 5)

# Wome n (25 & >)

# Youth Girls (1524)

# Girl s (<1 5)

Tot al

10

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Project Log:
Please keep track of your expenditures using this project log.

Volunteer Name: VAST Project Title: Implementation Period:

COS Date: Community Organization Name:

Date

Invoice Receipt

Description

Funds Expended (Local Currency)

Balance

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