Project Applicant:

Name:

E-Mail:

Institution/Organisation:

Country:

Project Summary – 1 line:

Project duration:

Project budget requested:

In local currency:

This project application form is divided into 5 sections:

SECTION A:General Project Information

SECTION B:Executive Summary

SECTION C: Project Description

SECTION D:Bank Account

SECTION E:Professional background of applicant

SECTION F:Signatures (pages to be faxed or scanned)

For additional pages, please mark clearly whether SECTION A, B, C, D, E or F.

The application will be considered if written in English.

Applicants should prepare their project applications at least 12 weeks in advance of the NNHF Council Meeting (see our website for dates of NNHF Council meetings) to ensure an efficient evaluation and approval process.

Please find the NNHF project guidelinesattached for further reference:

Experience shows that the steps in project planning which consume the most time and require detailed attention are the following: activity breakdown with budget estimates and timelines, assignment of responsibilities in the case of delegation to working groups or individuals, quarterly cost planning and establishment of a dedicated project bank account.

Thorough preparation and early discussion will facilitate decision making by the NNHF Council,leading to rapid project initiation.

Please do not hesitate to contact NNHF at the above address if you have any questions related to your project application or if you need assistance.
SECTION A –GENERAL PROJECT INFORMATION

1.SUBMISSION DATE:

2.PROJECT TITLE:

Project title should be descriptive and should consist of about 5 key words

3.COUNTRY/REGION:

Please state the country/region in which the project will take place

4.PERSON RESPONSIBLE FOR PROJECT

Name:

Title:

Institution/Organisation:

Street address:

City/ZIP code:

Country:

E-mail:

Tel:

Mobile:

Fax:

5.PROJECT PERIOD

Please state expected project start and end dates (month/year)

Start:

End:

6.OVERALL BUDGET REQUESTED:

Please indicate the overall budget sum requested in local currency

SECTION B - Executive summary

(Please stay within the spaceprovided)

1.PROJECT – EXECUTIVE SUMMARY (please summarise your project idea very briefly)

SECTION B - Executive summary

2.NATIONAL HAEMOPHILIA CARE AND TREATMENT STATUS

  • Please describe the health care environment as well as current status of haemophilia care and treatment in your country, i.e.
  • Health care system and haemophilia (reimbursement and insurance coverage)
  • Haemophilia infrastructure – diagnostic facilities, treatment centres, modalities (prophylaxis, on demand, home treatment) and standard (factor consumption (IU)/capita), existence of (active) patient association
  • Haemophilia patients – no. of patients, existence of local or national haemophilia registries
  • Challenges and opportunities in haemophilia care and treatment
  • Please explain how the project fits into this context

SECTION c - PROJECT DESCRIPTION

3.OBJECTIVES OF PROJECT

  • Please state the objectives of your project within the space provided

SECTION c - PROJECT DESCRIPTION

4.PROJECT PLAN & BUDGET

  • Please break down the objectives into milestones and activities you intend to carry out
  • Please define for each activity the deliverables and their measures of successful conclusion

SECTION c - PROJECT DESCRIPTION

Please indicate the budget currency (your local currency):

5.PROJECT BUDGETaccording to budgeting principles in project guidelines

  • Please refer to budgeting principles in attached NNHF project guidelines (see page 1) and indicate for each activity the approximate costs as per below Excel-template in your local currency:
  • In the following attachment you can find some important definitions, which will help you fill in the project budget template:

6.ADDITIONAL SOURCE OF FUNDING / COLLABORATORS on this project:

  • Please indicate in the case of additional funding sources of this project:
  • Collaborator/co-funder
  • Activity supported
  • Co-funding amount promised
  • Co-funding amount secured.
  • Please enclose documentation as evidence of co-funding.

SECTION c - PROJECT DESCRIPTION

7.PROJECT ORGANISATION AND INSTITUTIONAL FRAMEWORK

a. Please provide relevant information about your institution/organisation such as (but not limited to):

  • Year of establishment
  • Number of patients
  • Outreach (national, regional, local)

b. Please provide the following informationincludingresponsibilities of each person involved:

  • Overall project responsible
  • Institutions, authorities and/or other organisations involved and their roles in the project
  • Delegation to Committees, Working Groups or management individuals; please state who is included in them or to whom a task is delegated.
  • How do you plan to organise the collaboration

SECTION c - PROJECT DESCRIPTION

8.SUSTAINABILITY

  • Please state what the project will achieve in terms of lasting value, e.g. publications, guidelines, laboratories etc.
  • Please explain how the activities initiated here will be utilised and/or continued after project conclusion.
  • Please state who will continue theseactivities/achievements.

SECTION c - PROJECT DESCRIPTION

9.ANY OTHER RELEVANT INFORMATION

SECTION c - PROJECT DESCRIPTION

10.PROJECT ASSESSMENT

a.QUANTIFIABLE PROJECT BENEFITS

  • Please state the expected number of peoplewho will benefit from the project and how – e.g. doctors, nurses, lab technicians, trainers, patients, etc.

SECTION c - PROJECT DESCRIPTION

b.DELIVERABLES DOCUMENTATION

  • Please indicate what documents/materials will be delivered throughout the project, e.g..educational materials, training plans, guidelines, posters, slides, models, photographs, published papers, regular project report, final project evaluation

SECTION c - PROJECT DESCRIPTION

c.MAJOR RISKS

  • Please state
  • What factors may prevent achievement of the objective(s) or cause considerable delay(s).
  • Precautions that will be taken to reduce the risks or limit their impact.

SECTION d–bank account

1.BANKING INFORMATION

In order to finance its programmes, NNHF transfers funding money to project sites at quarterly intervals based on the receipt of a quarterly Progress and Cost Report, and annually, of an Audit Report. The banking information is an essential part of the project.

Please provide the following information requested in the grey areas:

Account holder*:

Account holder address

Street:

Postcode/town:

Country:

Telephone- and fax number:

Name of account:

Account number or IBAN code:

Signatories to account

(at least two):

Beneficiary Bank:

Bank address

Street:

Postcode/town:

Country:

Telephone- and fax number:

Bank branch:

Bank Swift or SORT CODE:

(International identification code)

*Identical with project partner

SECTION e –PROFESSIONAL BACKGROUND of APPLICANT

1.SHORT RÉSUMÉ OF APPLICANTS’ PROFESSIONAL EXPERIENCE

  • Only professional (academic/organisational) experience relevant to the application is required.
  • Please also attach aCV (maximum 2 pages) as a separate item or, if the application is filled out electronically, forward separately by e-mail to or fax to +41 43 222 4343.

SECTION e –PROFESSIONAL BACKGROUND of APPLICANT

2.LIST OF APPLICANT’S OWN PUBLICATIONS / APPLICANT’S EXPERIENCE IN THE AREA

  • Only published work by the applicant(s) is required.

SECTION e –PROFESSIONAL BACKGROUND of APPLICANT

3.REFEREES

Please state names and addresses of two persons who can be contacted to verify the credentials of the applicant(s).

Referee 1

Name:

Title/function:

Institution:

Street address:

City/Zip code:

Country:

E-mail:

Tel:

Mobile:

Fax:

Referee 2

Name:

Title/function:

Institution:

Street address:

City/Zip code:

Country:

E-mail:

Tel:

Mobile:

Fax:

SECTION f– SIGNATURES


1.Applicant

Project title:

Project applicant:

______

Signature of project applicant

______

Signature of project applicant’s department/institutional head

2.Legal representative(s) of the institution/organisation (if not identical with applicant

______

Name of legal representative(s) of the institution/organisation

______

Signature of legal representative(s) of the institution/organisation

SECTION f – SIGNATURES

3.Health authority/organisation/haemophilia associationendorsing your project (if applicable)

The undersigned hereby confirm that the Project is endorsed by:

______

Authority/organisation/haemophilia association

______

Signature of authority representative(s)

4.Any other organisation co-funding your project (if applicable)

______

Organisation

______

Signature of organisation responsible

NNHF Project Application FormPage 1 of 20