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?)
 
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.)
5 Has organization previously been blacklisted by a national authority, funder or fund manager?
 
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)  
Estimated annual budget of the organization (inclusive of the largest funder), in US Dollars  
     
       
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
Financial Management and/ or Admin Manual  (operational documents, not statements or reports)
Operations Manual
Human Resource Manual
M&E (indicate if harmonized with national M&E manual for the specific disease or for the health sector)
Procurement/ store/ supply management manual
Audit manual if available
Any other (please explain)
       
 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 / project 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 investor/ donor funded project?    
Many signatures will be /are required for fund  transfers     
Accounting system  
Does organization have a chart of accounts/ different books/ classification of different sources of funds (and does/ will this include largest source of funds?)
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 the largest source of grants/ funding?    
Did the audits also cover non-financial issues?           
Have all the issues observed in the auditor’s previous 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 (Including corporations, individuals, and foundations)
Others
       
Infrastructure, Equipment, and Supplies  
Does the organization have adequate infrastructure (office space, information systems, communications, computer equipment, etc.) to support the activities (to be) implemented? Will the organization 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 from an external source?          
Is the organization involved in training any data collectors or M&E staff?          
       
     
       
       
Summary Scores for Organization:    
Country    
Summary score sheet (Calculated automatically - do not enter data)      
Area   Actual Score  
Project/ 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 (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