Chương trình hợp tác WHO.-BYT. DFC. Cost norm

 

 

Viet Nam Country Office

Direct Financial Cooperation (DFC) Application Form

(To be submitted at least 1 month before beginning activity)

 

Part I – Cover page:

 

Title of DFC	DFC Start Required by Date	DFC Completion Required by Date	Total DFC Planned Amount (VND & USD)
	Click here to enter a date.	Click here to enter a date.

 

 

Approval on behalf of the Implementing Partner (IP):

 

Name of Implementing Partner:        

Full Name of IP’s Director/Officer-In-Charge:          

Title:        

 

Signature (with Stamp):………………………………………………………………………………

 

Date:  ………………….……………………………..………………………………………………………

 

Name of IP’s focal point/responsible officer for this DFC activity:           

 

Contact details (email/telephone/mobile):           

 

 

 

 

Part II -  Summary of DFC Activity, its objective(s), expected outcome(s) and deliverable(s):

 

1. Background: (The background should include: relevance/importance of the problem/activity and cite literature from credible sources)

     

 

 

2. Objective(s): (State overall objectives of DFC Request in "measurable" terms, the relevance of these objectives to PD Objective, WPRO Vision and expected results of the Viet Nam and WHO Health Cooperation Programme. Also state its contribution and link with national health plan, strategy, policies and or programme etc)

     

 

 

3. Expected Outcome(s):

• Identify the expected Outcome(s) of the Activity (in bullet points)

     

 

• Describe how the outcome(s) and impact be assessed at the end of the activity (How will we know that the planned results have been achieved? (Interviews, surveys, counts, pre-planned milestones etc.?):

     

 

4. Summary of Activity: (Description of DFC Activity, Also, explain how/if this activity builds on previous activities).

     

 

 

5. Monitoring and Follow-Up: (Explain the methods for monitoring and identify the follow-up actions that are intended to be taken (In bullet points) that you intend to use before, during and after the activity to assess its effectiveness)

     

 

 

6. Deliverables:

Deliverables       (Limit 240 characters with space)	Due date	% of Payment
Countersigned contract	Click here to enter a date.	Choose an item.
	Click here to enter a date.	Choose an item.
	Click here to enter a date.	Choose an item.
	Click here to enter a date.	Choose an item.
	Click here to enter a date.	Choose an item.
DFC report (Technical Report & Financial Report)	Click here to enter a date.	Choose an item.

Notes:  The contract printed out will show only the text in the “Deliverable” field. Same deliverables must be reflected when DFC Purchase Requisition is created in WHO Global Service Management (GSM)

The 1st mandatory deliverable must always be "Countersigned Contract". The wording of the 1st deliverable must be exactly as "Countersigned Contract". 

Interim technical report or interim financial statement is deliverables for long duration of DFC activity prior releases of new payment.

 Pre-and post-activity evaluation is required deliverable for training activity.

Translation products are required deliverable for the translation service with estimated budget requirement.

The final mandatory deliverable is the “DFC report” which has two parts:  A final DFC report comprising: 1) a technical report specifying the activities undertaken and outcomes achieved, as against the terms of reference and budget set forth in the Agreement, and 2) a financial certification using the Funding Authorization and Certification of Expenditure (FACE) form.  

 

 

 

 

Part III – Detailed descriptions of specific DFC activity (ies) to be implemented:

 

1. Activity 1:
2. Description of Activity: (in bullet points)

     

 

1. Time frame: (Specify planned date, or identify week and month)

     

 

1. Location:

     

 

1. Participants/Invitees, Resource persons and selection criteria:

• Indicate number of participants/invitees, resource persons

           

 

• Identify the selection criteria for participants/invitees, resource persons:

           

 

2. Activity 2:
3. Description of Activity: (in bullet points)

     

 

1. Time frame (Specify planned date, or identify week and month)

     

 

1. Location:

     

 

1. Participants/Invitees, Resource persons and selection criteria:

• Indicate number of participants/invitees, resource persons:

           

 

• Identify the selection criteria for participants/invitees, resource persons:

           

 

3. Activity 3:
4. Description of Activity: (in bullet points)

     

 

1. Time frame (Specify planned date, or identify week and month)

     

 

1. Location:

     

 

1. Participants/Invitees, Resource persons and selection criteria:

• Indicate number of participants/invitees, resource persons:

           

 

• Identify the selection criteria for participants/invitees, resource persons:

           

 

Annexes:

Annex 1: Tentative Agenda - Use the template as a guide

 

Time	Content	Organizations in charge

 

Annex 2: List of Participants/Invitees – Use the template as a guide. (Please include a full list of participants including: their name and title, their position, the name of their department/organization, which city/province they are from and CVs if specifically requested)

Name & Title	Position	Gender	Department/Organization	City/Province

 

Annex 3: List of resource persons – Use the template as a guide. (Please include a list of all facilitators/trainers, including: names, position and brief CVs, with justifications for appointment)

 

Name & Title	Position	Gender	Department/Organization	Justification for Appointment

 

Annex 4: DFC estimated budget breakdown – Please include a full and detailed budget estimation in VND for each component of the activity, specifics including the duration, location, number of participants, per diem, daily subsistence rates, nature of travel, estimated travel costs, estimates of the number of documents to be translated and the specific nature of other costs.

 

Reminder: Once the DFC agreement is signed, the budget becomes final. During the implementation phase, transfers between expenditure categories are only authorized up to an amount not exceeding 10% of the amount initially allocated to the category from which or to which the transfer is made. WHO prior approval must be obtained in writing when the amount to be transferred exceeds 10%.

 

Activity 1:
Timeframe:
Location:
Descriptions	Unit	Rate (VND)	Days/Person	Total Amount (VND)	Total Amount (USD)
Sub-Total:

 

Tệp đính kèm:

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17-04-2023