Project Classification

HIV/ AIDS Project Area: X Prevention Care

Infrastructure Development NGO Development Income Generation Instructional Materials

Resources/ Equipment and Supplies

Training

PEPFAR PROJECT PROPOSAL / COMPLETION REPORT

1 What community need does this VAST Project address?
a. What are the objectives of this project? b. List the main activities per each objective mentioned above.

How will the project contribute to building skills and capacity within the community/ NGO? How will the community/ NGO be able to sustain the benefits of this project? Does this project relate to your primary assignment, or is it a secondary project?
To be filled out by Peace Corps Staff:

Priority Grouping Country: Ukraine Project Title: Community Group: Project Implementation Period: Volunteer Name:

Fiscal Year:

Project Number:

From COS Date: Male Adults

25+ Yrs

To

Female Adults
25+ Yrs

Youth Boys
15-24

Youth Girls
15-24

Boys
under 15

Girls
under 15

Total

# of Participants, beneficiaries, and service providers involved in or benefiting from this project (This should be the TOTAL number of individuals from data on pages 3-4)

PROJECT COST BREAKDOWN (IN $USD):

Please enter in US Dollars ONLY! Labor Equipment Materials/Supplies Land/Venue Rental Travel/Per Diem Materials transport Other Total

VAST Grant

Community Contribution Cash In-kind

Third Party Contribution(s) (if any) Cash In-kind

Third Party Name(s)

WHAT WILL VAST FUNDS PURCHASE (attach detailed itemized budget)? Category Description Labor (honoraria only; salaries are not permitted) Equipment Materials and Supplies Venue Rental Travel/Per Diem (maximum of 500 USD) Transportation of Materials Other: (be specific)

Monitoring and Evaluation: 1. Indicate here your output indicators for measuring progress. Note that each project objective should have at least one output indicator to measure your progress. Also indicate how you measure this indicator. Example: Output indicator #1: 10 trainings for 200 people conducted by December 2007

2. Indicate here a) your outcome indicators and b) how you will measure them. There should be 2-3 outcome indicators to measure your impact on knowledge, attitudes and/or behaviors of those who are participating in your project. Example: Outcome indicator #1: 40 training participants can both correctly identify the methods of HIV transmission and reject major misconceptions about HIV. This will be measured using pre-and post training questionnaires.

3. On the next two pages, you will find a menu of PEPFAR indicators. Peace Corps is required to report on these indicators for any projects that use PEPFAR resources. These numbers are rolled into a country report, which is presented to Congress and is used to justify further funding. Please report only the indicators that are relevant to your project. First, for prevention-related activities, determine if your project 1) promoted abstinence and/ or being faithful, 2) promoted abstinence only, or 3) was not focused on abstinence and/ or being faithful. You only need to report in one of the sections (1, 2, or 3) for each question. Please report individuals assisted separately from service providers (ie. teachers, doctors) trained.

A. How many individuals--men, women, boys, and girlswill be assisted by Volunteers doing HIV/AIDS activities? Do not include service providers-people trained to do programs (see question B) Do not double count! Prevention activities (see definitions below) 1. Activities to promote abstinence and/ or Type of being faithful Prevention Men Women Youth Youth Boys Girls Activity 25 25 and Boys Girls under under
and over over 15-24 15-24 15 15

2. Activities to promote abstinence only

(NOTE: This is a sub-set of abstinence and/or being faithful activities)
Men 25 and over Women 25 and over Youth Boys 15-24 Youth Girls 15-24 Boys under 15 Girls under 15

3. Activities not focused on abstinence and/ or being faithful

Men 25 and over Women 25 and over Youth Boys 15-24 Youth Girls 15-24 Boys under 15 Girls under 15

Community outreach Mass media Prevention (community outreach) includes programs, services, and activities to help prevent transmission of HIV/AIDS such as community outreach, peer education, classroom and small-group education, and sexually transmitted infections (STI) management services. Prevention (mass media) includes development and/or distribution of HIV/AIDS related materials via print, radio, TV, Internet, and other media.

B. How many service providers (called Trainees or Persons Trained on PEPFAR form) were trained by Volunteers to provide HIV/AIDS programs/services who were men, women, youth boys, and youth girls (for example, youth might be trained as peer educators): Do not double count! Prevention activities (see definitions below) Type of Prevention Activity 1. Activities to promote abstinence and/or being faithful
Men 25 and over Women 25 and over Youth Boys 15-24 Youth Girls 15-24

2. Activities to promote abstinence only

(NOTE: This is a sub-set of abstinence and/or being faithful activities)
Men 25 and over Women 25 and over Youth Boys 15-24 Youth Girls 15-24

3. Activities not focused on abstinence and/ or being faithful

Men 25 and over Women 25 and over Youth Boys 15-24 Youth Girls 15-24

Community outreach Mass media Prevention (community outreach) includes programs, services, and activities to help prevent transmission of HIV/AIDS such as community outreach, peer education, classroom and small-group education, and sexually transmitted infections (STI) management services. Prevention (mass media) includes development and/or distribution of HIV/AIDS related materials via print, radio, TV, Internet, and other media.

APPENDIX 1
To Completed PC Staff PROJECT NUMBER: Be by

VAST PROJECT AGREEMENT

Community Organization: Volunteer Name: Implementation Dates: Budget: Local Contribution VAST Amount

PEACE CORPS/*Ukraine*

COS Date:

$ $

Local Currency Local Currency Local Currency Local Currency

@ @ @ @

% % %

Third Party $ Contribution Total Project Cost Fiscal Data: $

OGAC Budget Coding Category: Other Prevention

Authority: (leave blank) IN WITNESS WHEREOF, the (*COMMUNITY ORGANIZATION*) 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 Community Official Organization Signatur e: Name: Title: Date: Diana Schmidt Peace Director Corps Country

APPENDIX 2 Volunteer Activities, Support and Training (VAST) Program Peace Corps Volunteer CONSENT AND LIABILITY ACCEPTANCE
By signing this statement, I agree to accept PEPFAR/VAST funds on behalf of (insert name of Counterpart Organization) and for the purpose of implementing VAST Project (leave blank). I assume responsibility for managing these funds in accordance with PEPFAR/VAST Program guidelines, and for obtaining the necessary original invoices and receipts for all purchases or expenditures made in connection with this PEPFAR/VAST Project. I will account for the use of these funds by returning to the Peace Corps/Ukraine PEPFAR Coordinator at the end of the Project all allowable receipts and any remaining cash. To the extent possible, all purchases and payments drawn against the VAST Project will be made by check ordered through Peace Corps/Ukraine. To decrease my own personal liability, I will work closely with my community group or counterpart organization to establish a funds management system and/or community or Project bank account and, when possible, utilize account-to-account transfers for major purchases. For any and all transfer of PEPFAR/VAST funds to my community or counterpart organization, I will obtain a signed, dated, and witnessed receipt, and record the transfer on the PEPFAR/VAST Project Log. I understand that any loss of PEPFAR/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 funds. I further understand that my liability with respect to this Project is limited to the management of funds secured through this PEPFAR/VAST Project. I do not agree to accept responsibility for community generated or third party contributions to the Project, nor any liability with respect to on-going activities after the objectives of the original Project PEPFAR/VAST are completed. Peace Corps Volunteer (Printed Name)_______________________________________ Peace Corps Volunteer Signature _______________________________________ __Andrey Khomenko________________ _______________________________________ _______________________________________ _______________________________________ ___________________________________________ Check Amount: Date of Check:

Administrative Officer (Printed Name) Administrative Officer Signature Witnessed by (Printed Name) Witness Signature Date Check No. : VAST Project Reference: VAST Project Title: