SAMPLE. Embassy of Japan in Nigeria Grant Assistance for Grass-roots Human Security Projects (GGP)

Embassy of Japan in Nigeria Grant Assistance for Grass-roots Human Security Projects (GGP) APPLICATION FORM for FY 2017 * FY 2017 = Japanese Fiscal Year 2017 (1 st April 2017-31 st March 2018) NOTE: (1) Please Type or Print Clearly (Hand writing CANNOT be accepted) (2) Submission Deadline: Tuesday, 31 st, January 2017 (3) Submission of this Application Form is just for the purpose of its assessment by the Embassy of Japan in Nigeria (hereinafter referred to as the Embassy ) and does not provide any bases for claiming against it. (4) The Embassy will not be responsible for any costs incurred in the process of application. 1. Project Summary (1) Project Title: The Project for Construction of ABC Primary Health Care Centre in Abuja Municipal Area Council in the Federal Capital Territory (2) Project Summary: Construction of ABC Primary Health Care Centre and installation of medical equipment and tools (3) Total Amount of Funds Requested for the Project (naira): 24,986,000 Naira 2. Details of Applicant 2.1 Background Information (1) Name of the applicant organisation: Nigeria Japan Forum (2) Postal address of the head office: No.9, ABC Street, ABC, Abuja Municipal Area Council, FCT (3) Phone number and Email address of the organisation, Phone number: 0803-111-1111-1111 Email Address: abc@abc.jp (4) Representative of the organisation Name: ABC Title: Ms. Position: Country Director 1 / 13

Phone number: 0803-111-1111-1112 Email Address: abc@abc.def.jp * NOTE: Representative of the organisation stated above should be the person who will sign the Grant Contract upon approval of the proposed project by the Embassy s Headquarters in Tokyo, Japan, and who is duly authorized and has the legal capacity to execute and deliver the Contract and make any decision relating to the Contract in your organisation. (5) Contact Person Name: DEF Title: Dr. Position: Project Manager Phone number: 0803-111-1111-1113 Email Address: abc@abc.def.hij.jp *NOTE: Contact person stated above should be a focal point to the Embassy and has to be in frequent contact with the project coordinator of the Embassy. If your proposed project is approved, contact person is requested to monitor the project progress and report the progress and/or changes to the coordinator on a frequent basis. 2.2 Registration (1) Year of establishment of the organisation: 2000 (2) Year of registration of the organisation: 2002 (3) Principal place of activity of the organisation: Lagos State and FCT (4) If the organisation is an international one, i. Please provide the address of the headquarters abroad: 1000, Hon-Machi, Mitaka City, Tokyo, Japan ii. Representative of the organisations HQ Name: HIJ Title: Ms. Position: Executive Director Phone number: +81-111-1111-1111 Email Address: abc@abc.abc.com iii. If the organisation is an international one, is the office in Nigeria duly authorised to operate independently from the headquarters? Yes it is. Nigerian office is independent from the HQ in terms of finance and management of the project, and registered in Nigeria. Ms. ABC, country director therefore can sign a Grant Contract as well. 2 / 13

(e.g., to sign a Grant Contract; to implement, finance and manage the project; etc.) 2.3 Organisational Structure (1) Number of personnel Paid full time workers 20 Paid part time workers 10 Volunteers 10 TOTAL 40 * The number in the table above excludes that of the board members. (2) Branch/liaison offices within Nigeria and their locations Name of branch/liaison office Postal address Lagos Branch Office No.100, ABC Street, Ikoyi, Eti-Osa Local Government Area, Lagos State 2.4 Purpose and activities of your organisation (1) Purpose of the organisation (as detailed as possible) The Purpose of the organisation is to improve people s access to the primary health care services in Nigeria, particularly in the FCT and Lagos State, by constructing primary health care centre, installing medical equipment and tools, as well as advocating the government to represent community needs. We also work for the people in the community especially pregnant women and children to organise public health campaign, for instance, to facilitate utilisation of mosquito net to prevent malaria, and make sure immunisation activities, to create people s interest on their own health. (2) Main activities of the organisation (as detailed as possible) First, we construct a primary health care centre in the FCT and Lagos State to achieve government goals of one PHC per ward. We have a monthly meeting with the FCT Administration and Lagos State Ministry of Health to coordinate our plans. We, so far, have constructed 7 primary health care centres in Lagos and 7 centres in FCT. Second, we assist to install medical equipment and tools in both primary health care centres and general hospitals. Most of those items are for the maternal/child health. Third, we have a public health campaign for countering malaria and HIV/AIDs as well as immunisation campaign in Lagos Mainland LGA, Lagos State and in Bwari Area Council in the FCT. We usually organise those campaigns with other donors, such as XYZ foundation and AbcAID. 2.5 Financial statements of the organisation (1) If the organisation has ever been funded by the Embassy s GGP in the past, please specify the name of the project and the date of Grant Contract. 3 / 13

Date of Grant Contract Name of the Project 15 December 2011 The Project for Construction of LMN Primary Health Care Centre in Lagos Mainland Local Government Area in Lagos State 11 June 2005 The Project for Procurement of Hospital Medical Equipment for ABC General Hospital in Abaji Municipal Area Council in the Federal Capital Territory (2) Has the organisation ever received any financial/technical assistance from foreign governments, international organisations, government agencies or NGOs? Please describe 3 major projects the organisation has had so far since establishment in the table below chronologically with the name and summary of the assistance project/programme as well as the amount funded. Name of donor Year Name and summary of the assistance project/programme ABC Council 2012-2015 (1) Name: The Project for construction of PHC Centre in the FCT. (2) Summary: The project is to newly construct or renovate primary health care centre to improve people s healthcare access in the FCT, by constructing 2 PHC Centres (A PHC Centre and B PHC Centre) and installing medical equipment and tools in those facilities. AbcAID 2010-2012 (1) Name: The Project for immunisation Campaign in the Federal Capital Territory. (2) Summary: The project is to hold 14 immunisation campaign, called One-day Special Immunisation Free Campaign to make people s awareness and appropriate knowledge for the immunisation especially for children. ABC Foundation 2007-2009 (1) Name: The Project to Improve Health Care Access in Lagos State. (2) Summary: The project is to improve people s primary health care access in Lagos State, by constructing five PHC Centres (A PHC Centre, B PHC Centre, C PHC Centre, M PHC Centre and O PHC Centre) and installing medical equipment and tools in those facilities. Amount funded (specify the currency) Contact of the Donor for the further reference 450,000 USD Mr. Mohammed ABC, Director, ABC Council: 0803-111-1111-1113 / abc@abccouncil.com 300,000 USD Ms. Bello ABC, Country Director, AbcAID, 0701-111-1111-1111 / abc@abcaid.com 940,000 USD Dr. Elizabeth ABC, Director General, ABC Foundation: 0803-222-1111-1111 / abc@abcfoundation.com 4 / 13

* Please write the organisation s projects in the above table even if the organisation has never received any financial/technical assistance from foreign governments, international organisations, government agencies or NGOs, and also state who donated the funds for those projects. 3. Information of the Proposed Project Site 3.1. Location of the proposed project site * Please note that an applicant organisation cannot have the project implemented in some areas of Nigeria due to security deterioration, and you are recommended to inquire from the Embassy of Japan for more details. (1) Name of community (or district): ABC community (2) Name of LGA/Area Council: Abuja Municipal Area Council (AMAC) (3) Name of state: Federal Capital Territory (FCT) 3.2. Information on the Beneficiary (1) Population of the targeted community (Year/Source): Year Population (No.) Note (Recent Demographic change/reason) 2014 35,000 There is 7.5 % increase in 2 years/due to influx of immigrants (IDPs) fleeing from some parts of the Northern parts of the country, there is at least 5% surge in the population. In addition, cost of living in ABC site is relatively low compared to that of Abuja city centre, which further encourages the movement. Info. Source National Bureau of statistics (2) Main economic activities in the community and the main sources of incomes of the targeted people and information source. * If the main economic activity is farming, please specify what farmers produce and how often they get access to the market. Main Economic Activity: The original inhabitants of the community are predominantly farmers who mainly are into yam farming, with a once in a year harvest season. (Access to market is very easy because a major market is located in close proximity, within the community). However, because of frequent influx of immigrants due to lower cost of living compared to the city centre, a growing population of civil servants, artisans and traders etc. have taken the centre stage, economically. Currently, the population of immigrants outweighs that of the original inhabitants Source(s): One-on-one interview from community head and residents 5 / 13

(3) Average monthly income (per household) and information source: Average monthly income: 46,600N/month (For farmers: N30, 000 / For Artisans: N45,000 / For Civil servants: N65,000) Source: One-on-one-Interviews with 300 residents in 2015 (4) Has the organisation ever worked with the community before? If yes, please describe the project and its details. Yes, one of the projects stated above (funded by ABC council from 2012-2015) was implemented in CDE PHC Centre (a neighbouring community to ABC). Name of project: The Project for construction of PHC Centre in the FCT. Summary: The project was to newly construct as well as renovate primary health care centre to improve people s healthcare access in CDE site in the FCT, by constructing 2 PHC Centres (A PHC Centre and B PHC Centre) and installing medical equipment and tools in those facilities. We worked closely with the two communities (ABC and CDE) with the intention to construction in both communities at the same time. But as a result of the limited fund, although we gathered every necessary information from ABC district, we could not implement the project in this community. That is why we are using this opportunity to fulfil our promise to the community through the GGP scheme of the Embassy of Japan. If not, please state how the organization knows the community and their challenges for the first time? 3.3. *For the Project to Support Existing Facility Only NOTE: If the project is related to supporting any existing facilities (e.g., to provide medical equipment to a general hospital), you are requested to fill in this Section 3.3.. (1) Name of the Facility (e.g., XXX hospital/primary Health Care Centre): (2) Year of Establishment of the Facility (3) What kinds of services/products are provided in the facility? (4) What is the main problem that the facility currently faces? 6 / 13

(5) (For existing health facility project only) Number of beds, patients, staff and relevant information of the facility for the last three years * Please fill in the table below with reference to the example shown in the top of the table. Year Number of Beds Number of Patients Number of staff Condition of wards/equipment Example 2100 Maternity Ward: 8 General Ward: 6 Maternity: 340 In patients: 1100 Out patients: 2240 Doctors: 3 Nurses: 7 Accountant: 1 2014 2015 (1) The maternity ward is a tentative shack and in a very unhygienic condition without functional delivery beds. (2) The general ward needs to be renovated and 8 more beds are required to accommodate more patients. Because of lack of beds, patients often need to lie on floor. 2016 (latest info.) 3.4. Needs and Feasibility (1) Social background of the community NOTE: Please describe the challenges in the community to be tackled in the proposed project indicating as much quantitative data with statistical evidence as possible. As mentioned above, ABC community has a population of 35,000 (as of 2014 survey) and with 7.5% increase in 2 years, there is currently 37,625 people in the community with about 45% indigenes (i.e. about 16,931 population). Currently, unfortunately, there is no single public primary health centre in the community to serve at least this population. Though two private hospitals are situated in the community but most of the populations cannot afford to private hospital bills. Hence, the people of ABC community travel about 15km to the neighbouring ABC Primary Health centre that we recently constructed and commissioned. In fact, it was far worse before 2015 because they mostly had to travel to CDE district hospital for any major illness or deliveries. Currently, up to 5 to 7 pregnant women and children die annually as a result of the lack of quick access to PHC centre within the community and burdensome transportation fee (approx. 1,500N during the day and 2,500N in the night). Actually, pregnant women and 3 of the youths (a farmer) lost their lives last year. (2) Objective of the project (e.g., to improve the productivity of cassava processing for small-scale farmers by building and equipping a cassava processing centre in XXX community, to empower women by constructing vocational centre and training them with income generating skills such as XXX and XXX.) The project will improve health situation of the people in the community (37,625 population) and provide adequate health facilities at lowest cost. The health facility and equipment to be procured will change the community to have a first-hand health care service without any time loss and people s worrying of any more risks 7 / 13

of death. Also, most challenges will be promptly taken care of, because we ll also educate the people to quickly attend to their health challenges as quickly as possible. This is because many choose to manage their illnesses since there is no facility in close proximity, until it gets to a critical stage. (3) Justification of the project NOTE: Please describe reasons why the project has to be chosen among a large number of applications. Please explain in detail what the organization has seen and/or heard from expected beneficiaries in its needs assessment process, and what made this project is the most needed among other needs, referring to the particular needs identified in the community, not only from the general viewpoint of Nigeria. As a matter of fact, from our interaction with the community (especially the community head), every year, a letter is usually sent to the FCT Administration notifying them of the urgent need for a health centre in the community. For instance, for lack of adequate income, being farmers, many pregnant women choose to visit a local midwife but difficult labour such as haemorrhage, hypertension and cesarean section endanger lives of mothers and infants. For instance, precisely 4 years ago, the village head s cousin s twin-daughters had a still-birth in the hand of the local mid-wife. (It was considered a taboo). It was so painful that the community unanimously decided to form a committee that will ensure that a befitting health centre is constructed in the community. It was in the process that our NGO got in contact with the community s committee. That was when we began to conduct our survey and saw the need for this project. But unfortunately, due to lack of sufficient fund, we could not hold with the last project. That is why we insist that this year, we must assist this particular community! (4) Expected effects of the project NOTE: Please provide the number of beneficiaries of the project and describe what positive effects/changes the project will bring to the lives of beneficiaries. Please also describe how they will benefit from the project. - Total number of direct beneficiaries: As stated above in 3.4 (1), the number of beneficiaries is 37,625 people. - Expected effects/changes: As a result of the project, except for natural causes of death or accidents, it is expected that there will be zero mortality rate. No more waiting until critical period for lack of access to health facilities before visiting the PHC. There will be less out-of pocket-expenses on health related cost. The propose facility, therefore, will contribute to reduce the mortality rates especially for pregnant women and the burden of infectious diseases including malaria, TB and HIV/AIDs. 3.5. Sustainability of the Project NOTE: Detailed planning for ensuring the sustainability of project outcomes after the completion of the project is essential in order for the proposed project to be approved. The facilities/equipment funded by GGP should be utilised in the long term so that they would be able to bring about as much benefits/positive impact to/on the targeted community. (1) Who will be the owner of the facilities/equipment funded by GGP? (e.g., XXX State Ministry of Health, XXX Local Government Authority) 8 / 13

FCT Administration will own the facility and has the responsibility for maintenance of the building and procured medical equipment and other item. It will also have the responsibility to send sufficient number of medical personnel, at least 4 medical doctors, 10 nurses and 5 pharmacists. In addition, the community head has assured the NGO that the community forms ABC development committee which composed two health professional members from NGO, three representatives of the community, two members from inhabitants, two members of Abuja Municipal Area Council to deal with small problems of the facility as well as the security matter. (2) Who will be in charge of the management for the maintenance of the facilities/equipment? The Head of PHC Board in FCTA will be in charge of the management of the health facility. (3) How much will be cost per year for the maintenance? 800,000 Naira to operate the facility in terms of providing consumable including drugs and tools and for minor repairs. (4) How will the institution in charge of maintenance secure the funding for the maintenance? Based on the discussion with the PHC Board of the FCTA, it ll commit to make sure to include the above mentioned expenditure into the every years necessary health-related FCT budget as the cost for the maintenance. The Board, which manages and coordinates medical personnel in every clinics/hospitals in the FCT will also commit to send the sufficient number of medical staffs to the PHC Centre. (5) How will the members of community be involved for the maintenance of the facilities/equipment? The community already has a standing committee in charge of anything related to the community development. As a result, this ABC Development committee, which has at least a representative of the community head (community head a chairperson), a secretary general, members of trustees as well as some elected members of the community will be involved in the maintenance and liaison with government and NGO. Also, this committee will as well constitute at least 2 Abuja Municipal Area Council (from the government side). (6) Other Comments about the Sustainability of the Project The committee will meet frequently to monitor the use, in conjunction with NGO and FCTA and provide feedbacks to the community from time to time. This will furnish the entire community on the latest information from government including national issues of note that could involve individuals. The committee will ensure information is passed unto all community members and give feedbacks and involve them when there is any need for any major needs for renovations in future. 4. SUMMARY OF THE PROJECT BUDGET (Please use the template below to draw the summary of the project budget as detailed as possible.) No. Description GGP Fund (NGN) Contribution by Organisation (if any) Reason why the product/services should be provided through the project 9 / 13

1 Health sensitization Training(1 week) N250,000 Health sensitization Training. This will be just before the commissioning to help the community on how to use maintain, sustain and the facility 20,530,000 - To provide adequate medical services for the community 3,456,000 - To provide adequate medical services for the community 2 Construction of health facility 3 Procurement/installation of medical equipment and tools 4 Power generator 100,000 - For secondary supply of power in (20KVA) case of power failure 5 GGP signboard 200,000 - For promotion of the Japanese-GGP Scheme 6 2Water tanks 100,000 - For water storage 7 Borehole (industrial drilling) 230,000 To provide sufficient water 8 Independent Audit 600,000 To make sure project progress and completion TOTAL 24,986,000 480,000 10 / 13

Letter of Intent Nigeria Japan Forum (hereinafter referred to as the Organisation ), I hereby declare that all statements contained in this application are true and correct and understand that false or inaccurate information in the application will be the basis for termination of any agreements that may be made between the Embassy of Japan in Nigeria (hereinafter referred to as the Embassy ) and the Organisation hereafter. The Organisation agrees that it has no legal basis to claim against the Embassy until a Grant Contract will be made upon approval of a proposed project. If requested, the Organisation will provide any additional information relating to the project to the Embassy. The Organisation further agrees to comply strictly with any relevant laws and regulations as well as all GGP rules and requirements including, but not limited to, the basic ones listed below upon execution of the Grant Contract. The Organisation agrees: 1) to choose a contractor/supplier with BOQs in accordance with the Embassy s cost analysis procedure; 2) to install GGP signboard in accordance with the Section 14 of the Information Sheet; 3) to accomplish the project as planned including supervision of the contractor during the project and monitor all the items funded by the Embassy of Japan even after the completion of the project; 4) to complete the project within one (1) year from the date when the Grant Contract is signed; 5) to open new bank accounts (Naira and US Dollar accounts) to utilise GGP funds exclusively for the purpose of the approved project; and to reimburse the funds and/or authorise the Embassy to withdraw the funds in the joint bank accounts (Naira and US Dollar account) for the project, in any, for reimbursement without the signature of the Organisation s representative if the Organisation is in material breach of its obligations under any agreements with the Embassy of Japan; 6) to be responsible for any bank charges including, but not limited to, those for currency exchange and transfer of GGP funds; 7) to be responsible for any losses incurred by currency exchange of GGP funds; 8) to bear any extra-budgetary costs which may arise in the execution of the project and complete the project as planned; 9) to accompany embassy staff for the following monitoring visits to the project site: (i) a preliminary visit, (ii) an interim visit, (iii) a completion visit, (iv) a follow-up visit after two (2) years after the completion of the project; and to be responsible for any travel expenses for staff of the Organisation for each visit at the expense of the Organisation; 10) to visit the project site at least once a week during the implementation phase of the project, and to actively report the progress of the project to the project coordinator of the Embassy via email or phone on a weekly basis; 11) to submit the following documents without delay: i. Interim Report within six (6) months from the date the grant contract is signed; ii. Final Report upon completion of the project; iii. Financial Report including all original and/or certified receipts; and iv. Audit Report of the GGP funds utilisation issued by an independent auditor; 12) to consult the Embassy on any modifications/changes concerning the project plan (changes of layout, 11 / 13

contractor, project site, design of building, specification of equipment, etc.) and inform the Embassy of any reasons/justification in writing before making the modifications/changes; and understand that any modifications/changes without the Embassy s prior approval constitute a material breach of the Grant Contract; 13) to reimburse any remaining balance and/or exchange gains of GGP funds, if any, to the Embassy upon completion of the project without the Embassy s prior approval to use the balance and/or exchange gains for the purpose of the project. 14) to hold a hand-over ceremony of the project outcomes to which a representative of the Embassy will attend; 15) that if the Organisation is in material breach of its obligations under any agreements with the Embassy of Japan, the Embassy of Japan shall be entitled to terminate the approved project and claim a refund of a portion or the whole of the grant; 16) to monitor and supervise the project after the completion through a regular visit to the site and; 17) to comply and be bound by all other documents signed in relation to the project, including the Grant Contract. Date (d/m/y): 1/11/2016 Name: ABC Position: Country Director Signature: 12 / 13

CHECK LIST FOR ACCOMPANYING DOCUMENTS Attachment No. Accompanying Documents Please Attachment 1 Registration certificate of the organisation Attachment 2 Attachment 3 Attachment 4 Attachment 5 Attachment 6 Attachment 7 Attachment 8 Attachment 9 Board member list with their contact information (only when the organisation has a board of trustees) Organisation s articles of incorporation Organogram (organisation chart) Audited financial reports for the last two years State map indicating the project site clearly Photographs of the proposed project site (facilities/equipment) Two Reference Letters from different donors One Bill of Quantity from one contractor/supplier for each item For Construction Project Only: Attachment 10 Certificate of land ownership Attachment 11 Design specification of the construction (MUST include the detailed architectural designs(by qualified Architect), mechanical ( including water supply) & electrical (M&E), and structural plans) (End) 13 / 13