CAMBODIA DISABILTIY INCLUSIVE DEVELOPMENT FUND (CDIDF) PROJECT PROPOSAL APPLICATION TEMPLATE

(Applications should follow this template which includes a suggested length for each section of the proposal; applicants are encouraged to be clear and concise.)

Section 1:

Project ref. no.: (for CDIDF Official use only – do not write anything here)

Project title:

Target province(s)

Project timeframe: From: (month and year) To: (month and year)

Total project budget: US$

Budget contribution sought from UNICEF: US$

Budget contribution from other donors (if applicable):

US$

Specific expected results to be achieved with this funding:

Strategic partners:

Target beneficiaries:

Name of organisation:

Year established: (Reference of registration with MoI or MoFA)

Mailing address:

Telephone:

Fax:

Email:

Organisation contact:

Name:Title:Mob:Email:

Date submitted:

Page 1 of 13

Section 2:

1. History/ background of organisation (1/2 page)o Describe in brief your organisation

2. Organisation’s mission and vision o Write here your organisation’s mission and vision

3. List of other donors (including previous donors) and projects/ activities funded by other donors

Project Name Dates Donor name Donor contact details

Agreement Amount

Please add more row as needed

Section 3:

a) Project description (see Attachment C for Glossary of terms) (In brief, what is it you want to do?) (3/4 page)

b) Background to the proposal (Why do you want to do this project? What is this project responding to?) (3/4 page)

c) Project objectives (what do you hope to achieve with the project?) (1/2 page)d) Impact of the project/ expected results (how will this affect your project beneficiaries, what

difference will it make to them?) (1/2 page)e) Beneficiaries – direct and indirect (who will benefit from your project?)

Describe the beneficiaries for your proposed project (1/2 page). Identify direct beneficiaries as well as ones who will indirectly benefit from the project. Where possible include numbers as per below table:

Activities Direct/ Indirect

Adult Male

Adult Female

Boy(0-17 year old)

Girl(0-17 year old)

Adult with a disability

Child with a disability

Urban Rural UXO Survivors

Activity 1 DirectIndirect

Activity 2 DirectIndirect

Activity 3 DirectIndirect

Overall DirectIndirect

Page 2 of 13

f) Possible risks/ challenges to the project and how the organisation plans to deal with them

Risk management is an important component to the proposal. Using the below matrix, please include an analysis of risk associated with your proposed project.

Risk (description)

Risk Impact Probability & Impact Rate1 - Low, Medium, High.

Mitigation ActionProbability Impact

L M H L M H

e.g. Rainy season makes it difficult to access communities

x x Community-based activities are planned during dry season and transportation during rainy season is costed and included in the budget.

xxxxxxxxxx x

g) Project location (where will you implement, be specific where possible) (1/4 page)h) List of other organisations with whom you will be collaborating on this and other projectsi) Project duration j) Describe the community consultation undertaken to identify the need for this activity and the

communities’ link/engagement with your organisation (1/4 page)k) Inputs (1/2 page)l) Project activities (what are the key activities you are proposing in your project?) (1 page)m) Outputs (1/2 page)n) If this project involves providing training, please provide a copy of the training manual you plan

to use and/ or a one page summary of the training

1 How likely is the risk to happen and how significant would the impact of the risk be on your proposed activities?

Page 3 of 13

Section 4: (3/4 page)

Describe how your project will contribute to at least one of the two 2014 funding priorities of CDIDF and keep in mind the cross-cutting issues and principles of the CDIDF. For more information on these, see the Application Guidelines:

I. Disability sector work that engages and strengthens the link with local decision makers and commune councils to achieve inclusive local development.

II. Support to work in gap areas – this means gaps in service availability, gaps in geographic coverage, gaps is specific types of disability and gaps as identified by applicants in support for persons with disabilities. The following are examples, however applicants are not restricted to these: services in screening and early detection, early childhood interventions, access to education for children with disabilities, support for intellectual disabilities, psycho- social disabilities, services for women with disabilities, services related to visual and hearing impairments and disability related services in remote areas.

Section 5:

Please provide a work-plan and schedule of activities (see Attachment B below for template)

Page 4 of 13

Section 6:

Please provide and monitoring and evaluation (M&E) plan for your proposed activity.

Objective Activity Output Resources Required Indicator

Measure taken every (eg. 3m,

6m, 12m):Timeframe

Page 5 of 13

Section 7:

Please provide a budget for the proposal (see Attachment A for the budget template). The budget should capture the activities and objectives of the proposal.

Section 8:

Your organisation’s grant funding application must include evidence of:

Adequate Board/Committee oversight and engagement:

a) Describe how often the Committee/Board meets and their role in your organisation’s governance

b) Provide minutes from their last Committee/Board meetingc) Detail your organisational structured) If it exists, provide a copy of the constitution of your organisatione) Demonstrate past capacity to deliver projects and engage in staff developmentf) Demonstrate established administrative and financial systemsg) Organisations need to attach 2014 quarterly bank statements and your organisation bank

account detailsh) Entire Organisational Operational Budget i.e. Finance and Expenditure (Global Budget) i) Provide evidence of registration as an NGO/organisation in Cambodia with MoI or MoFA j) Annual Report

Please note that should your proposal be selected, the organisation’s director/manager and finance staff will be required to attend UNICEF provided grant finance training before receipt of the grant.

Section 9:

Grant application checklist

Before submitting your application, please use this checklist to ensure your application is accurately completed. Incomplete applications will not be considered.

Have you confirmed that your organisation is eligible to apply? (Check eligibility list below) Have you indicated the geographic focus areas where the funding will be utilized? Have you completed the project description and given details of your budget? Have you advised us of other sources of funding your organisation may receive? Have you indicated the target beneficiaries for your project? Have you included all the supporting documents required? Refer to Section 8 Have you provided the name of your Chair, Director and Finance Manager and have they agreed

to the application form? Have you kept a copy of your application for your organisation’s internal records?

Page 6 of 13

Eligibility List

International and national non-governmental organisations (I/NGOs), community-based organisations (CBOs) that are:

formally registered in Cambodia (MoI or MoFA) working in the grants scheme target geographic areas Complying with the Community Based Rehabilitation (CBR) guidelines (work

that contributes to: support services to persons with disabilities; support for children with disabilities; organisations which seek to empower persons and give voice to persons with disabilities; etc.)

Existence of an oversight Committee or Board Clearly defined organisational mandate Sound institutional/operational capacity to deliver the proposed project:

admin/finance, M&E, reporting, child protection and social welfare services Ability and willingness to work with government at any levels Ability and willingness to work with other organisations The project is aligned with the 2014 funding priorities Participation in UNICEF led training activities (pre-agreement finance training, budget and

financial governance)

Page 7 of 13

Agreement and declaration

I certify that the statements in this application are true. I have read and understand the Grants Program Guidelines.

I acknowledge that if CDIDF approves this application for a grant, I will be required to meet the eligibility criteria as outlined in the Grants Guidelines.

I acknowledge that late applications will not be accepted.

I acknowledge UNICEF may vary the level of funding provided through the program at its sole discretion.

I acknowledge that UNICEF cannot guarantee funding for any application, and cannot guarantee funding to the full amount requested by any applicant.

I have been authorized to submit this application on behalf of (Organisation name):

Full name:

Position in organisation:

Signature:

Date:

Completed applications should be posted, faxed or delivered to:

Attn: Chhignim Kuoch, Community Development OfficerTel: (855-23) 426 214/5; 427 957/8 (Ext. 128)Mobile: (855-12) 912 331Fax: (855-23) 426 284 E-mail: CDIDF@unicef.org United Nations Children's Fund (UNICEF) P.O. Box 176, No. 11, Street 75Sangkat Sraschark, Phnom Penh 12201

Page 8 of 13

ATTACHMENT A: BUDGET TEMPLATE

NOTE: Overall budget and administration costs must reflect size of the activity.

BUDGET (in US$ or local currency)Project Cooperation Agreement Title:

Period: Start: DD/MM/YY End: DD/MM/YY

UNICEF ContributionsNo. Items Unit Qua

ntityUnit Cost Total Budget Partner’s

ContributionsOther Donor’s Contribution

Total UNICEF’s Contribution

1st Tranchedd/mm/yy

2nd Tranche dd/mm/yy

3rd Tranche dd/mm/yy

4th Tranche dd/mm/yy

1. Programme Costs* 1.11.21.31.4

Sub Total2. Programme Support Costs**2.12.22.32.4

Sub TotalBudget SummaryProgramme CostsProgramme Support CostsTOTAL

Page 9 of 13

* Programme Costs are the costs of inputs, such as:

Cash for activities, such as workshops, training (venue rental, accommodation or logistics) Cost of supplies that directly assist beneficiaries or beneficiary institutions Materials production and distribution Costs of surveys, reviews, consultations and results-related evaluations Technical assistance to support beneficiaries or beneficiary institutions Communication that directly supports the programme objectives

** Programme Support Costs are costs attributable to the management and administration of the programme that can be identified as arising directly and unequivocally from its implementation. These may include costs associated with reasonable accommodation and accessibility.

Page 10 of 13

ATTACHMENT B: WORK-PLAN

WORKPLAN

UNICEF Cambodia and name of CSO

Result ActivitiesTimeframe (in quarter)

Responsible Partner

Budget (US$)

Q1 Q2 Q3 Q4Partner’s

contributionOther donor’s contribution

UNICEF’s contribution Total

TOTAL

SCHEDULE OF ACTIVITIES

Activity Description Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

Activity 1

Activity 2

Activity 3

Page 11 of 13

ATTACHMENT C: GLOSSARY OF TERMS

EXPLANATION OF TERMS USED IN THE CAMBODIA DISABILITY INCLUSIVE DEVELOPMENT FUND FORM

PROGRAMME:A program is a group of related and somehow interdependent projects with the objective of achieving (often intangible) outcomes and benefits for the organisation. A program, as opposed to a 'project', can also be across different organisations.

PROJECT:A project is a temporary endeavour, having a defined beginning and end (usually constrained by date, but can be by funding or deliverables, undertaken to meet unique goals and objectives, usually to bring about beneficial change or added value.

OBJECTIVE:Objectives are the concrete statements that describe the things a project is trying to achieve. A project objective should be written so that it can be evaluated at the conclusion of a project to see whether it was achieved.

One technique for writing an objective is to make sure that it is SMART - Specific, Measurable, Attainable/Achievable, Realistic, and Time-bound.

Objectives should make reference to the deliverables of the project.

The following are examples of SMART criteria objectives:To provide 40 women and children with disabilities transportation to health centres by December 2014 To increase the understanding of the needs of women and children with disabilities, in 4 local communes by community leaders and decision makers by December 2014.

Use positive change words (increase, improve) to emphasise the benefits of the objectives.

ACTIVITY:Activities are the actions or processes that the organisation undertakes with/to the client in order to to achieve the objects. for example, training, teaching, counselling, providing medical intervention, sheltering, family counselling, monitoring, lobbying government etc.

INPUTS:Inputs are materials and resources that the organisation uses to carry out its activities, or processes e.g. equipment, staff, volunteers, facilities, money, etc.

Page 12 of 13

OUTPUTS: Outputs are the direct and measurable products of a project’s activities or services, often expressed in terms of units (hours, number of people or completed actions). For example, the number of people trained, provided with medical services, counselling, shelter, reports/press releases published etc., pamphlets distributed.

OUTCOMES:Outcomes are actual impacts/benefits/changes for participants during or after your project-- for example, for a prevention of violence against women and children with disabilities project, an outcome might be "police provide adapted responsive services for the rights of women and children with disabilities in contact with the law " (notice that this outcome is quite different than outputs, such as the "number of police who went through the training program on women and children with disabilities").

These changes, or outcomes, are usually expressed in terms of:

Knowledge and skills (these are often considered to be rather short-term outcomes) Behaviours (these are often considered to be rather intermediate-term outcomes) Values, conditions and status (these are often considered to be rather long-term outcomes)

INDICATORS:Indicators are observable and measurable “milestones” toward a target. These are what you'd see, hear, read, etc., that would indicate whether you're making any progress toward your outcome target or not, for example, the number of trainings held for commune police in the focus area. .

Page 13 of 13