Alumni Disability Initiative Grant (Pilot) -2018

Australia Awards – Nepal

Alumni Disability Initiative Grant (Pilot) -2018

Application Form

Full name/s of alumni:
Course studied in Australia (in full):
Institution/university:
Year of completion:
Type of Award*:
Current employer:
Position:
Telephone:
Email address:
Are you currently registered on the Australia Global Alumni Database? YES [ ] NO [ ]

* Only alumni from the Australian Government-funded Australia Awards Scholarships, Australia Awards Fellowships, or Short Course Awards; or another Scholarship or Fellowship program funded by the Australian Governmentare eligible to participate.

1. Activity Title:

1. Activity start and end dates:

1. Provide a title for your activity and briefly outline the purpose of the activity you would implement with an Alumni Disability Initiative Grant. Include an explanation of howyour activity aligns to DFAT’s Development For All StrategyMaximum 500 words

1. Please identify whether the proposed activity is a mainstreaming approach and / or a targeted approach to disability inclusion (tick relevant check box and tick both if your activity fits with both approaches)

Mainstreaming disability into broader activities: for example, including a disability perspective in to activities or services; actively including people with disabilities as participants and/or beneficiaries; engaging with local Disabled People Organisations / ☐ /
Targeted disability-specific support and services: for example, providing assistive devices to support mobility or communication; supporting inclusive education;strengthening Disabled People Organisations; community-based rehabilitation; promoting business and economic sustainability for people with disability / ☐ /

1. Please identify how the activity will address a single aspect or any combination of the following principles:

Increasing awareness and understandingin order to sensitise people to disability inclusion; building awareness of the barriers and forming strategies to remove them
Increasing participationby ensuring that people with a disability are participating in decisions that relate to them
Removing barriers/increasing accessibilityto ensure that physical or environmental, communication, policy and/or attitudinal barriers are identified and addressed

1. Please provide some detail on the intended primary participants or beneficiaries of the activity, using as many of the following categories as are relevant:

People with a disability / Where possible, insert an estimate of number and/or the gender ratio (% of women and men, % of girls and boys)
(Your)organisation / For example, number of staff that will benefit through training
Disability service providers / Where possible, insert number and type of provider/s
Disabled people’s organisations (DPOs) / Where possible, insert number and type of DPOs
Government organisations focused on disability e.g. Ministry of Education / Health; Social Welfare Council (SWC), / Where possible, insert number and type of government organisations
Wider community / For example, name of community or region, and where activity will take place, e.g. community centre, tourist centre etc.
Other (private organisations, schools, mainstream organisations, governments) / Please list any other primary participants who do not fall into the above categories

1. 7. Activity Costs in Australian Dollars

/

1. AUD

Overall budget for activity. Please attach detailed budget using the template in Annex 3.
Amount requested from the Alumni Disability Grant Initiative (up to a maximum of AUD 1,000):
Are there other sources of funding? If so, how much will be provided?
Source of funds (state the organisation):
Total:
If this grant is approved, will it be sufficient to complete this activity? / YES/NO
If you have applied for other sources of funding, would this activity proceed
if this grant is approved but funds from other donors are not forthcoming? / YES/NO
Certification
I certify that the information in this application is true and accurate. / YES/NO
I agree to provide a full acquittal of grant funds and a completion report upon completion of the activity. / YES/NO
I agree to participate in a Fraud Awareness and Child Protection Briefing before receiving funds. / YES/NO
I agree to be involved in publicity of the activity if required. / YES/NO
I agree to participate in surveys and/or interviews to share the outcomes/impact of the grant. / YES/NO
Name: / Signature: / Date:

All queries on the Alumni Disability Initiative Grant should be directed to Australia Awards Nepal:

Tel+977- 1- 400-2614 or email:

Annex 1: Activity Work Plan Template

SN / Activity / Responsible / Budget (AUD) / Apr / May / Jun
1 / Induction on Fraud Management and Child Protection / Australia Awards
2 / Disbursement of grants / Australia Awards
3
4
5
6
7
8
9 / Submit Financial Acquittal Report
10 / Submit Activity Completion Report
TOTAL

Please add rows and columns to the plan as necessary.

Annex 2: Budget Template

Alumni name:

Title of Activity:

Income (in AUD)
Source / Amount
1. Alumni Disability Initiative Grant
2. Other sources of funding
TOTAL
Planned Expenditure (in AUD)*
Item / Unit / Unit Cost / # of Units / Amount
TOTAL EXPENDITURE

DECLARATION:

I (applicant)...... , certify that,

a)the above information is an accurate and complete representation of planned expenditure;

b)the expenditure of the grant will be solely for the activity;

c)the interim and final acquittals will include correct record of income and expenditure for this activity;

d)There will be compliance with all terms and conditions of the agreement and all necessary disclosures will be made.

Signature: ______Position: ______

Name: ______Date: ______

Mobile No: ______Email Address: ______

* The total activity costs must equal the total sources of income.

Annex 3: Application Checklist

Please complete this checklist before submitting your Alumni Disability Initiative Grant application

SN / Checklist / Yes/No
I have read and understood the Concept Note & Guidelines
I have read and understood DFAT’s Development For All strategy
I have read and understood DFAT’s Fraud Control & Anti-Corruption Plan, and Child Protection Policy 2017
I have providedan accurate and complete Application Form
I have providedan accurate and complete Activity Work Plan (Annex 1)
I have provided an accurate and completeActivity Budget (Annex 2)
I have provided a clear description of how the Grant will assist the proposed activity and make a positive development contribution in the field of disability
I have registered on the Australian Government Global Alumni Website:

Annex 4: Financial Acquittal and Declaration

Date / Details of Expenditure / Expenditure Reference / Actual Expenditure (NPR)* / Budgeted Expenditure (AUD)
TOTAL EXPENDITURE
TOTAL GRANT RECEIVED
NET SUM DUE TO BE RETURNED (if any)

*Note: grants will be disbursed in NPR (equivalent of AUD 1,000) as per OANDA currency exchange, hence actual expenditure must be reported in NPR.

DECLARATION:

I (grant recipient)...... , certify that:

a)the above information is accurate and complete;

b)the expenditure of the grant received to date has been solely on the activity outlined in the application and described in this report;

c)the balance of any funds not disbursed will bereturned;

d)the interim or final acquittal is a correct record of income and expenditure for this Project/Activity;

e)there is no matter or circumstances of which I am aware that would constitute a breach by us of any term of the Alumni Disability Initiative Grant between us and Australia Awards dated [ ] that has not been notified to the Australia Awards.

Signature: ______Position: ______

Name: ______Date: ______

Mobile No: ______Email Address: ______

Please email or post your completed acquittal report and supporting documentation to the Australia Awards Nepal Office by 15 August 2018.

Annex 5: Completion Report Template

Activity Title:
Name(s) of Grantee:
Date Prepared:
Activity Start and End Dates:
Activity Description:

Consistency with Activity Outcomes:

What were the achieved outcomes of the Activity?
List the performance indicators presented in the proposal, and the achievements against them
Indicator: / Target: / Achieved: / Reasons for Variance:

Target Groups:

Explain how the project has contributed to have a positive impact on persons with disabilities
Describe how the project has impacted on men and women, specifically.
Explain how the project has contributed to have a positive impact on children

Activity Beneficiaries:

Direct :
Persons with disability, benefitting from the Activity: / Female / Male
Indirect (if relevant)
Beneficiary type: (explain who they are) / Female / Male

Consistency with Collaboration Outcomes:

Did the activity foster linkages/partnerships with other organizations and/or individuals?
Synergies – how has the activity been complemented and/or sustained by other activities funded from other sources?

Challenges:

Explain the hindering factors that impacted on the progress of the activity and how you overcame.
Unintended Outcomes: Describe positive or negative outcomes that the activity has unintentionally brought.

Lessons Learned:

Describe what worked well. What aspects of the project were particularly successful and why?
What went wrong and why?
What would have been done in a different way to bring better outcomes?