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Please enter or select data in BLUE coloured cells only		Comments / Remarks	Score
ORGANIZATIONAL BACKGROUND			Do not enter data in this column
1 Name / Title of Organization
2 Contact details of Organization (mailing address, phone numbers)
3 Physical Address (Does organization exist physically?)			"0"
4. Country or Territory
4.a Indicate if State, Province, District or County of operation is a hard to reach area (desert, flooded, mountainous region, etc.)			"0"
5 Has organization previously been blacklisted by a national authority, funder or fund manager?			"0"
6 Name of person(s) completing this form (Optional)
7 Telephone number (this is temporary; it will be deleted following data verification)

PREVIOUS GRANTS & PERFORMANCE
Types of interventions and activities implemented/ to be implemented under your current budget (in case you have not received funding yet, indicate what you plan to implement)
Target populations reached / main results expected (e.g. number of people reached - (Insert % value of main indicator (from project records)
Total amount of grant(s) from largest donor to organization (indicate currency and year granted)	0
Estimated annual budget of the organization (inclusive of the largest funder), in US Dollars	0


Does organization have any of the following documents (organizational and operational manuals, plans, etc.): (Yes or No)
Type of manual, plan or guidelines	Select Yes or NO as appropriate (Indicate YES if institution has adopted the use of a centrally developed manual, such as Government or Largest Funder manual)	Indicate "Yes" below if manual or similar document was collected or provided
Annual or grant-specific work plan and budget			"0"
Financial Management and/ or Admin Manual (operational documents, not statements or reports)			"0"
Operations Manual			"0"
Human Resource Manual			"0"
M&E (indicate if harmonized with national M&E manual for the specific disease or for the health sector)			"0"
Procurement/ store/ supply management manual			"0"
Audit manual if available			"0"
Any other (please explain)			"0"

Staff and structure
Who is expected to manage or who manages the grant (s). How many full-time staff, part-time staff, and volunteers implement? What are their roles? Does it have a technical advisor? If so, who?
Area	Number and title of staff/ volunteers or advisors
Availability of Largest Funder Unit within organization, or unit that implements the Largest Funder grant (Yes / No)
Total number of full time staff within the institution (or Estimate to the nearest 5 or 10)
Total number of volunteer or part time staff to the nearest 10
Programme management staff (including Manager)
M&E Staff (or staff collecting, analyzing, verifying data)
Finance officers, Accountants or other finance staff
Procurement and supply officers if any
Other staff (please list)
Any outsourced functions (e.g. implementation, IT , book keeping, M&E, etc.)
Technical advisors?

Staff Capacity Building
Types of training	Number of staff trained	Topic and how long the training lasted (days, weeks, months, years?)
Number of employees trained in financial management and systems the last 1 year
Number of employees trained in M&E (including M, E, Reporting and data quality assurance) during the last 1 year
Number of employees trained on project implementation, management or supervision during the last 1 year
Any other training


Insert the positions of staff that will be directly implementing the Largest Funder grant, e.g. manager, accountant, M&E officer, etc. over 75% of the time.

Organization’s Strengths and Achievements
20.1 Partner organizations
20.2 Target / beneficiary populations or interventions
20.3 Achievements

Organization's challenges
List main Challenges faced and weaknesses if any. In organization’s opinion, how can each of the weak areas be strengthened? - What are the problems that the organization has faced in grant (TB, HIV, malaria or HSS) implementation or management. - What is the organization’s track record for timely and results based implementation of activities? - Has the organization reported in a timely manner for all past periods?). - In its own view, in which of the following areas does the organization’s employees require capacity building most urgently? (Finance, M&E, Grant Implementation, management, other?
21.1 Implementation challenges
21.2 M&E Challenges
21.3 Financial management challenges

Financial management capacity
Can organization correctly record all transactions and balances, including those supported by the Largest Funder; can it disburse funds to suppliers in a timely, transparent and accountable manner; maintains an adequate internal control system; can it support the preparation of regular reliable financial statements; can it safeguard its assets; and is it subject to acceptable auditing arrangements? Please select YES or NO from drop down menu and indicate risks alongside if any.		Key comments/ Strengths/ Risks, after answering YES or NO next to the question
Organization of the Financial Management function
Does organization have more than 1 accounting personnel?
Are accounting duties segregated (shared by more than 2 people?)
Budget system (Institutional, not necessarily Largest Funder only):
Are financial/ budget reports prepared for management? (If Yes how regularly?)
Are the budgets approved by a senior team or the head of institution?
Are staff salaries decided on the basis of what govt/ other donors/ organizations pay? (Describe at end of column)
Treasury system
Are bank accounts held in organization’s name ?
Does the organization generate cash forecast into the next few months?
Is there a limit for operations petty cash, imprests, withdrawals etc.
If yes is it pre-approved?
Is there or will there be a separate account for GF grants?
Many signatures will be /are required for GF transfers
Accounting system
Does organization have a chart of accounts/ different books/ classification of different sources of funds (and does/ will this include Largest Funder grants?)
Are there systems to monitor actual spending against the budget periodically?
Does the organization have/ keep copies of financial records (receipts invoices etc) for at least 3 years ago?
Is the financial management system computerized?
If YES, what is the name of the accounting software used?
Are financial reports of the organization produced regularly
If YES, specify how often
Purchasing system
Are decisions on what to purchase made by more than one individual/ or by committee?
Is there a documented process for procurement of non health products and services?
Assets management system
Is there a system of adequate safeguards to protect assets, e.g. labeling, register?
Are assets insured?
Has a physical inventory or count of assets /stocks been done in the last 2 years?
Audit arrangements (External and Internal)
Has the organization been audited externally at least once every year for the last 3 years?
Did / Will the audits also cover Largest Funder grants?
Did the audits also cover non-financial issues?
Have all the issues observed in the auditor’s report been addressed?

Sustainability: Other sources of funding and program support
	Select if support received	If YES, indicate type or amount in support
Community
Government
Bilaterals (Other governments- PEPFAR, DfID, SIDA, etc.)
Multilaterals (UN , esp. WHO, World Bank, etc.)
International NGOs
Private Sector
Others

Infrastructure, Equipment, and Supplies
Does the SR have adequate infrastructure (office space, information systems, communications, computer equipment, etc.) to support the activities under the Grant(s)? Will the SR be able to work in key areas/regions where activities are planned to be implemented?		Remarks
Office Space (indicate "YES" only if there is adequate space; explain if "No" ; e.g. at least an 8 by 5 ft room at village level, at at least 2 of these at district level
Desktop Computers (indicate YES only if more than 2 computers in the organization)
Laptop Computers
Mobile phones
Landlines / Desk Phones
Vehicles in use (indicate YES, only if at least one vehicle will be dedicated to project)
Software used to keep and report on financial records
Software / documents used to keep M&E Records and report
Printer
Archive/ library of documents (either online or offline)

What are immediate needs/priorities to be addressed by moneys received? Does the organization plan to scale up? (Increase the numbers reached/ targeted?)	vehicles needed for cordination,help in setting up a hotline for community outreaches.

Monitoring, Evaluation, Data Quality Assurance and Reporting
M&E Budget		Remarks/ Issues/ Risks
Does the organization have an M&E budget ?
What is the proportion of the M & E to the overall budget (%)
M&E Human Resource Capacity /Coordination
Does the organization have fulltime staff on M&E?
M&E tools and guidelines
Does organization utilize an M&E plan, manual or guideline?
Does organization utilize standard data collection tools?
Routine data collection, analysis and reporting
Does the organization collect data at least once a month?
Does the organization report the data to donors / fund managers within the agreed deadlines ?
Data quality assurance and M&E related supportive supervision
Does the organization supervise data collectors?
Does the organization provide supervision to implementers in the community?
Has the organization performed any data verification in the last year?
Evaluation, Operational Research, surveys, surveillance, special studies
Has the organization evaluated its project or been evaluated within the last 2 years?
Has the organization(s) implemented recommendations from this evaluation?
Has the organization / staff participated in any health surveys in 3 past years?
Information products, dissemination and use
Has the organization shared its last 12 monthly reports with the funder within the deadline?
Has the organization implemented all the recommendations of the grantor or auditor?
Has organization prepared a programme report that details its results and other achievements in the last 12 months
Implementation of M&E work plan
Does the organization have a work plan for M&E ?
Has its implementation been reviewed within the last year?
Contribution to National M&E system strengthening
Is the organization receiving a grant to implement M&E activities under the Health Systems Strengthening grant, from the Largest Funder?
Is the organization involved in training any data collectors or M&E staff?




Organization:
Country
Summary score sheet (Calculated automatically - do not enter data)
Area		Actual Score
Grant implementation and management capacity (Max score of 15)
Previous implementation, results and capacity building efforts (Out of 12)
Evidence of regular coordination with partners (out of 3)
Internal organizational systems (maximum score 25)
Governance, strategic or operational documents available and harmonized as per GF requirements (out of 5)
Adequate staffing at all levels (max. 12)
Adequate software and equipment (max 8)
M&E and reporting capacity (maximum score 30)
Capacity for timely reporting of results (max.14)
Capacity for complete and regular reporting (max. 10)
Capacity to produce and verify quality of data (max 6)
Financial management and reporting systems (maximum score 25)
Adequate accounting, budgeting, treasury and audit arrangements (max. score 10)
Capacity to produce accurate financial reports in a timely manner (max. 10)
Evidence of good financial management practices and capacity building
Equity and risk considerations (max score 5)
Total Score