Professional Documents
Culture Documents
Table of Contents
Application Instructions
1. Project Classification
2. Project Description
3. Goals and Objectives
4. Timeline
5. Monitoring and Evaluation
6. Do No Harm
7. Detailed Budget
8. Grant Type Selection Menu
9. Signature Forms
Form PC-2105
To be filled out by the community partner with the help of the PCV
PINK CELLS
BROWN CELLS
COMMENTS ON CELLS:
Please take note of the red triangle at the top right corner of certain cells (including this one).
These have been included on many cells to help guide users through each step of the process.
PROTECTED CELLS:
Each one of these sheets is protected and will allow data only to be entered in areas that are
shaded in pink or blue. This is done to ensure that all data entered is of the correct type to be
used in reporting within Peace Corps.
Form PC-2105
Project Number:
Project Title:
Project City/Town/Village:
Region:
Months
1 0.0333333333 0
Weeks
D
ay
s
Number of PCVs:
Volunteer Information:
Last Name
First Name
COS Date
Primary PCV
PCV 2
PCV 3
Responsible Program Manager/APCD:
Project Classification
(Mark only one classification with "XX" as the primary classification of this project. Mark additional applicable descriptors with an "X.")
Agriculture
Municipal Development
HIV/AIDS
Food Security
Education
ICT
Environment
Youth Development
NGO Development
Health
Volunteerism
Form PC-2105
Males
Females
Under 15 years
old
25 years old
Under 15 years
15 to 24 years old
and above
old
Total
# of Participants (direct):
Community members directly involved in the design
and implementation of the project, including those
who attend trainings or workshops
# of Beneficiaries (indirect):
Community members who receive an indirect benefit
from the project, not including those counted above
Grant Contribution
Community Contribution
Cash
Cash
In-kind
Cash
In-kind
Labor
$0.00
$0.00
$0.00
$0.00
$0.00
Equipment
Materials/Supplies
Land/Venue Rental
Travel, Per Diem, Food
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Materials Transport
$0.00
$0.00
$0.00
$0.00
$0.00
Other
$0.00
$0.00
$0.00
$0.00
$0.00
Total
$0.00
$0.00
$0.00
$0.00
$0.00
Budget Narrative
Please provide a general list of what items or services will be funded.
Grant Contribution
Community Contribution
Labor
Equipment
Materials and Supplies
Land/Venue Rental
Travel/Per Diem
Materials Transport
Other: (be specific)
Form PC-2105
Third-Party Contribution
(if applicable)
Directions
Your descriptions should be between 150 and 250 words. Please be succinct in describing your project and clearly outline the project's sustainability,long-term need, and the level of
community support for the project. Keep in mind that your application may be shared or distributed to donors and the agency.
Summary
Background
Community
Involvement
Outcome
Form PC-2105
Implementation
Capacity Building
Sustainability
Form PC-2105
Directions
What are the project's goals and objectives, and how will you know if your project is reaching them to produce the desired
benefits or change?
-- Use the tables below to state the project's goals and objectives and show how you will measure and evaluate the success
of your project. Establishing this during the planning phase of your project is essential for the community to measure its
success against the intended results.
-- At least one of your objectives should support your country program goals and strategies.
-- Your Goals & Objectives should contain your project targets, and may be useful for the program-specific Indicators section
later in this application.
-- You will report on these measures in the completion report.
Goal 1:
Objective 1.1
Objective 1.2
Objective 1.3
Objective 1.4
Goal 2:
Objective 2.1
Goals &
Objectives
Objective 2.2
Objective 2.3
Objective 2.4
Goal 3:
Objective 3.1
Objective 3.2
Objective 3.3
Objective 3.4
Form PC-2105
Directions
Please include a detailed project timeline for your implementation plan. Adjust the timeline below to fit your needs by choosing the appropriate time frame from the dropdown in cell H9. For example, if you
are doing a week-long camp, you would change the time from weeks to days by choosing "days" from the dropdown. Describe each activity necessary for project planning and implementation in the
"Activity" column, and the person responsible in the column to the right. Indicate when each activity will take place by placing an "X" in the appropriate day, week or month.
Approximate Implementation Period (auto-fills based off of start/end date on Project Classification page):
Months:
Weeks:
Example
Days:
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 1 Month 2
Activity
Person(s) Responsible
Organization president
Form PC-2105
Additional:
First, provide information for the global Peace Corps small grants indicators. Then, use the table below to list indicators for each of your objectives. For VAST, SPA, ECPA and FTF, there are also a pre-determined set of indicators
which are outlined later in this application. Please be sure to incorporate at least one of the pre-determined program indicators into this section of your project plan.
Capacity Development
Men, 25 and older
Women, 25 and
older
Men, 15-24
Women, 15-24
Boys, 14 and
under
Girls, 14 and
under
Men, 15-24
Women, 15-24
Boys, 14 and
under
Girls, 14 and
under
Organizations
Women, 25 and
older
Technologies
Practices
Form PC-2105
Objective
EXAMPLE
1
Who
When
GOAL
Indicator(s)
GOAL 1
1.2
1.3
1.4
2.1
GOAL 2
2.2
2.3
2.4
3.1
GOAL 3
3.2
3.3
3.4
Form PC-2105
Directions
In the design of any project, Volunteers and their community organizations should explore potential intended and unintended consequences of the proposed
interventions. This should consider the environmental, social, economic, and political aspects of project implementation. In designing projects, Volunteers should
investigate potential outcomes of the program in order to minimize negative outcomes. This is a participatory process and includes all stakeholders. The exercise
itself may be helpful in project design as it may identify areas of intervention needed to provide an enabling environment for the success of a Peace Corps project.
General
Environmental
Mitigation
Form PC-2105
Fill in the Project Information section at the top of this sheet. Please make sure to enter in the exchange rate. If you are not sure of the exact exchange rate, please enter your best estimate of the anticipated exchange rate for the dates of your project. If you
would like to enter amounts directly in U.S. dollars, leave the exchange rate at $1.
As you complete this Detailed Budget, the summary budget below and the budget on the Project Classification page will automatically fill in.
Enter a line for each expected cost the community will incur in carrying out the project. You should enter amounts in local currency. If you are filling out the form electronically, fill out all of the blue cells on each line. For the budget category, please select from
one of the seven options in the dropdown list. The total cost will fill in automatically by formula. For each item, the total cost should be split between grant amount, community contribution, and third-party contribution based on the proposed funding source for
the cost.
If you need additional rows, there are over 100 additional lines that are "hidden" at the bottom of the worksheet. Unhide the rows by following the instructions at the bottom of the sheet.
Directions
Project Title:
Project Information
Project Number:
Community Group:
APCD/Program
Manager:
Requested Project
Amount (in local
currency):
Exchange rate:
$1US =
% Community Contribution:
Total Project Cost USD:
Budget Summary
Community Contribution
Grant Amount
Category
Labor
Equipment
Materials/Supplies
Land/Venue Rental
Travel/Per Diem/Food/Lodging
Materials Transport
Other
- - -
Cash
Local Currency
-
$US
$
$
$
$
$
$
$
$
Form PC-2105
In-Kind
Local Currency
-
$US
$
$
$
$
$
$
$
$
Cash
Local Currency
-
$US
$
$
$
$
$
$
$
$
Grant Amount
Detailed Budget
Line #
1
2
3
Item Description
Budget Category
Unit Cost
Quantity
Total Cost
Cash
0.00
0.00
0.00
0.00
4
5
6
7
8
9
10
11
12
13
14
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Form PC-2105
Community Contribution
In-Kind
In-Kind
42
43
44
45
46
47
48
49
50
51
52
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
n/a
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total
n/a
n/a
Form PC-2105
n/a
0.00
0.00
0.00
0.00
0.00
0.00
Directions
Each funding source at Peace Corps has specific application requirements. Select the funding source through
which your project will be funded below to provide the information required by that program.
Please note that not all funding sources are available at every post. If you are unsure of which programs are
available in your country, please consult with post staff.
PCPP
SPA
Other
USAID
VAST
ECPA
FTF
Peace Corps Partnership Program (PCPP): Funded through donations from family,
friends and other donors in the United States. Available in every PC country.
Small Project Assistance (SPA) Program: Funded by USAID. Project activities must
fit within specific Program Elements. Please consult with post staff if you are
unsure which program elements your post has received funds in.
A few Peace Corps posts have arranged for country-specific grant programs funded
by USAID. Indicators for these programs will appear on the same page as the SPA
indicators.
Feed the Future (FtF): Funded by USAID. Projects must strategically respond to
food insecurity vulnerabilities. WAFSP is a regional partnership in West African
countries.
Form PC-2105
Title
First Name
Last Name
Street Address
Form PC-2105
City
State
Zip Code
Form PC-2105
Indicators
Environmental
Review
Form PC-2105
These data will be transmitted to Peace Corps/Washington to be used for internal Peace Corps reporting and for inclusion in the SPA annual report submitted to USAID/Washington. Information may also be shared with the in-country USAID Mission.
Directions: Choose the Program Element that the project is being funded under from the drop-down list below. Once you choose the Program Element, the indicators for that Program Element will appear. Please fill in information for the indicators relevant to your
project.
Country:
Program Element:
Example:
# of individuals who received a benefit from the project
12
Men 25 and
older
15
Women 25
and older
PC-2105
Men 15-24
10
Women 15-24
Boys 14 and
under
Girls 14 and
under
#N/A
#N/A
#N/A
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#N/A
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PC-2105
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Main Menu
SPA Menu
Instructions
Instructions
Project
Project Classification
Classification
Project Description
Goals & Objectives
Timeline
Timeline
Indicators
PCPP
PCPP
SPA and other USAID
VAST
VAST
ECPA
ECPA
FTF
FTF
Signature Forms
Liability
Liability Form
Form
Date:
Volunteer Name:
Project
Project Agreement
Agreement
Press Authorization
Location:
Attach a location map as well as site photos in color if possible
End
Project/Activity
Description:
Project/Activity
Description:
1. Earth Resources
a. grading trenching, or excavation in cubic meters or hectare
b. geologic hazards (faults, landslides, liquefaction, un-engineered fill,
c. contaminated soils or ground water on the site
d. offsite overburden/waste disposal or borrow pits required in cubic m
e. loss of high-quality farmlands in hectares
2. Agricultural and Agrochemical
a. impacts of inputs such as seeds and fertilizers
b. impact of production process on human health and environment
c. other adverse impacts
3. Industries
4. Air Quality
a. substantial increase in onsite air pollutant emissions (construction/o
b. violation of applicable air pollutant emissions or ambient concentrati
c. substantial increase in vehicle traffic during construction or operation
d. demolition or blasting for construction
e. substantial increase in odor during construction or operation
f. substantial alteration of microclimate
6. Cultural Resources
a. prehistoric, historic, or paleontological resources within 30 meters o
b. site/facility with unique cultural or ethnic values
7. Biological Resources
a. vegetation removal or construction in wetlands or riparian areas in h
b. use of pesticides/rodenticides, insecticides, or herbicides in hectare
c. Construction in or adjacent to a designated wildlife refuge
11. Other Issues (to be used for categories not captured under1 t
a. substantial adverse impact
b. adverse impact
c. minimal impact
ators
Environmental Review
Enter Y. M. N. or B
in the column
below
fertilizers
an health and environment
ion or extensification
30 meters of construction
face or ground water
gravel from, a river, stream or lake
dous materials in bulk quantities
ses
plans, permits or design factors
nated recreational area
of light or glare
onths
l service > 10 individuals for +6 months
mineral or non-renewable resources
bels for +3 months
tion
substantial congestion
o safety hazards
ess for anticipated volume of people or traffic
VAST Indicators
HIV Prevention- AB/OP
Male
Ages (in years) <10
10-14
15-17
Female
18-24
25+
<10
10-14
15-17
18-24
25+
Females
18+
<18
18+
Males
<18
Females
18+
<18
<18
Females
18+
<18
18+
PC-2105
18+
Males
<18
Males
18+
<18
Females
18+
<18
18+
Females
Females
NOT pregnant or
Pregnant and
lactating
Lactating
Males
<18
18+
<18
18+
<18
18+
Female
PC-2105
Small business entrepreneurs trained in developing business plans and financing strategies for renewable energy businesses
Entrepreneurs with improved business operations as a result of assistance [including starting or expanding their renewable energy small businesses]
Entrepreneurs and consumers successfully accessed bank loans or private equity as a result of assistance
Homes, businesses, or public locations adopt new energy efficiency practices as a result of assistance.
PC-2105
Outcomes
Renewable Electrical Energy (new or rehabilitated):
number of
installations
complete
community
members
who use kWhr/yr
at homes
in businesses
in public locations
at homes
in businesses
in public locations
Number of individuals living in households benefitting from new or rehabilitated cookstoves or ovens
in project abstract)
adult M
child F
child M
hours gathering fuel
PC-2105
Directions data. The sections below explain what is required for each section.
FTF Indicators
WAFSP Indicators
Environmental
Review form &
Assessment
Checklist
PC-2105
Dates
Project
Description
Sector
Goal 1
Obj. 1.2
1.1.b
Number of FEMALE farmers and others for the FIRST TIME applying new technologies or
management practices as a result of PC assistance (NEW) (4.5.2-5)
1.1.c
Number of MALE farmers and others CONTINUING to apply new technologies or management
practices as a result of PC assistance (CONTINUING) (4.5.2-5)
1.1.d
Number of FEMALE farmers and others CONTINUING to apply new technologies or management
practices as a result of PC assistance (CONTINUING) (4.5.2-5)
Goal 2
1.2.b
Number of FEMALE PRODUCERS who have received PC supported short-term agricultural sector
productivity or food security training (4.5.2-7) (PRODUCERS = Farmers, fishers, pastoralists,
ranchers, and other primary sector producers)
1.2.c
1.2.d
1.2.e
Number of MALE PRIVATE SECTOR who have received PC supported short-term agricultural sector
productivity or food security training (4.5.2-7) (PRIVATE SECTOR = processors, service providers,
manufacturers)
1.2.f
Number of FEMALE PRIVATE SECTOR who have received PC supported short-term agricultural
sector productivity or food security training (4.5.2-7) (PRIVATE SECTOR = processors, service
providers, manufacturers)
Obj. 2.2
2.1.a
Number of MICRO (1 to 5 FTEs) Enterprises (MALE owned) receiving PC assistance to access bank
loans (4.5.2-30)
2.1.b
2.1.c
Number of MICRO (1 to 5 FTEs) Enterprises (JOINT owned) receiving PC assistance to access bank
loans (4.5.2-30)
Number of SMALL (6 to 50 FTEs) Enterprises (MALE owned) receiving PC assistance to access bank
loans (4.5.2-30)
2.2.b
2.2.c
Obj. 2.3
Number of SMALL (6 to 50 FTEs) Enterprises (JOINT owned) receiving PC assistance to access bank
loans (4.5.2-30)
Obj. 2.4
2.3.a
Number of MEDIUM (51 to 100 FTEs) (1 to 5 FTEs) Enterprises (MALE owned) receiving PC
assistance to access bank loans (4.5.2-30)
2.3.b
Number of MEDIUM (51 to 100 FTEs) (1 to 5 FTEs) Enterprises (FEMALE owned) receiving PC
assistance to access bank loans (4.5.2-30)
2.3.c
Number of MEDIUM (51 to 100 FTEs) (1 to 5 FTEs) Enterprises (JOINT owned) receiving PC
assistance to access bank loans (4.5.2-30)
Obj. 2.5
2.4.a
Number of food security PRIVATE ENTERPRISES (FOR PROFIT) receiving FIRST TIME PC
assistance this year (NEW) (4.5.2-11)
2.4.b
Number of food security PRIVATE ENTERPRISES (FOR PROFIT) receiving PC assistance AGAIN
this year (CONTINUING) (4.5.2-11)
Obj. 2.6
2.5.a
Number of food security PRODUCER ORGANIZATIONS receiving FIRST TIME PC assistance this
year (NEW) (4.5.2-11)
2.5.b
Number of food security PRODUCER ORGANIZATIONS receiving PC assistance AGAIN this year
(CONTINUING) (4.5.2-11)
Obj. 2.7
2.6.a
Number of food security WATER USERS ASSOCIATIONS receiving FIRST TIME PC assistance this
year (NEW) (4.5.2-11)
2.6.b
Number of food security WATER USERS ASSOCIATIONS receiving PC assistance AGAIN this year
(CONTINUING) (4.5.2-11)
Obj. 2.8
2.7.a
Number of food security WOMEN'S GROUPS receiving FIRST TIME PC assistance this year (NEW)
(4.5.2-11)
2.7.b
Number of food security WOMEN'S GROUPS receiving PC assistance AGAIN this year
(CONTINUING) (4.5.2-11)
Obj. 2.9
2.8.a
Number of food security TRADE & BUSINESS ASSOCIATIONS receiving FIRST TIME PC assistance
this year (NEW) (4.5.2-11)
2.8.b
Number of food security TRADE & BUSINESS ASSOCIATIONS receiving PC assistance AGAIN this
year (CONTINUING) (4.5.2-11)
Goal 3
2.9.a
2.9.b
Obj. 3.2
3.1.a
Number of MALES trained in child health and nutrition through PC-supported health area programs
(3.1.9-1)
3.1.b
Number of FEMALES trained in child health and nutrition through PC-supported health area programs
(3.1.9-1)
3.2.b
PC-2105
Goal 4
Obj. 4.2
4.1.a
4.1.b
Number of more profitable CSOs engaged in agricultural and food-security-related manufacturing and
services now operating more profitably (at or above cost) because of PC assistance (4.5.2-43)
Obj. 4.3
4.2.a
4.2.b
4.2.c
4.2.d
4.2.e
4.2.f
4.2.g
4.2.h
4.2.i
4.2.j
4.2.k
4.2.l
4.2.m
4.2.n
4.2.o
4.2.p
4.2.q
4.2.r
4.3.b
4.3.c
4.3.d
4.3.e
PC-2105
Obj. 4.4
4.3.f
4.3.g
4.3.h
4.3.i
4.3.j
4.3.k
4.3.l
4.3.m
4.3.n
4.3.o
4.3.p
4.3.q
4.3.r
4.4.c
Number of MEDIUM (51 to 100 FTEs) Enterprises (AGRICULTURAL PRODUCER - JOINT) receiving
business development services from PC assisted sources (4.5.2-37)
4.4.d
Number of MEDIUM (51 to 100 FTEs) Enterprises (INPUT SUPPLIER - MALE) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.e
Number of MEDIUM (51 to 100 FTEs) Enterprises (INPUT SUPPLIER - FEMALE) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.f
Number of MEDIUM (51 to 100 FTEs) Enterprises (INPUT SUPPLIER - JOINT) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.g
Number of MEDIUM (51 to 100 FTEs) Enterprises (TRADER - MALE) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.h
Number of MEDIUM (51 to 100 FTEs) Enterprises (TRADER - FEMALE) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.i
Number of MEDIUM (51 to 100 FTEs) Enterprises (TRADER - JOINT) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.j
Number of MEDIUM (51 to 100 FTEs) Enterprises (OUTPUT PROCESSORS - MALE) receiving
business development services from PC assisted sources (4.5.2-37)
4.4.k
Number of MEDIUM (51 to 100 FTEs) Enterprises (OUTPUT PROCESSORS - FEMALE) receiving
business development services from PC assisted sources (4.5.2-37)
4.4.l
Number of MEDIUM (51 to 100 FTEs) Enterprises (OUTPUT PROCESSORS - JOINT) receiving
business development services from PC assisted sources (4.5.2-37)
4.4.m
Number of MEDIUM (51 to 100 FTEs) Enterprises (NON-AGRICULTURE - MALE) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.n
4.4.o
Number of MEDIUM (51 to 100 FTEs) Enterprises (NON-AGRICULTURE - JOINT) receiving business
development services from PC assisted sources (4.5.2-37)
4.4.p
Number of MEDIUM (51 to 100 FTEs) Enterprises (OTHER - MALE) receiving business development
services from PC assisted sources (4.5.2-37)
4.4.q
Number of MEDIUM (51 to 100 FTEs) Enterprises (OTHER - FEMALE) receiving business
development services from PC assisted sources (4.5.2-37)
PC-2105
4.4.r
Number of MEDIUM (51 to 100 FTEs) Enterprises (OTHER - JOINT) receiving business development
services from PC assisted sources (4.5.2-37)
PC-2105
Directions
Goal of the
WAFSP
Please estimate the indicator results you will be accomplishing and fill in these targets for the indicators relevant to the project in the
blue columns on the right
Ind. codes
4.5.2-5
Indicator Title
New or
Continuing
Female
Producers
4.5.2-7
Type of
Number of individuals who have received
individual
USG supported short-term agricultural sector
productivity or food security training
Sex
INCREASE FOOD SECURITY IN THE COMMUNITIES WHERE PCVs WORK IN WEST AFRICA
Continuing
Male
Sex
1. Increase availability
of healthy foods,
especially for women
and children
New
4.5.2-11
Size of
MSME
Number of MSMEs, including farmers,
receiving USG assistance to access loans
2. Increase
accessibility of healthy
foods by decreasing
poverty and increasing
incomes
People in Private
Sector Firms
People in Civil Society
Male
Female
Private Enterprises
Producer
Organizations
Water Users
Type of
Associations
organization
Women's Groups
Trade & Business
Assoc.
CBOS
New or
Continuing
4.5.2-30
People in Government
New
Continuing
Micro Enterprise
Small Enterprise
Medium Enterprise
Male owner
PC-2105
Value of the
indicator
(number)
2. Increase
accessibility of healthy
foods by decreasing
poverty and increasing
incomes
4.5.2-37
4.5.2-43
3.1.9-1
3. Improve utilization of
available food stuffs to
improve nutritional status
of women and children
Micro Enterprise
Small Enterprise
Medium Enterprise
Agricultural Producer
Input Supplier
Trader
Type of
MSME
Output Processors
Non-Agriculture
Other
Male owner
Sex of owner Female owner
Joint ownership
Size of
MSME
Custom indicat.
3.1.9-15
# of Firms
M
F
M
F
M
F
PC-2105
Indicator narrative
(write one paragraph on the story/activities behind the
figures by responding to the questions in brackets)
PC-2105
PC-2105
The purpose of this Environmental Review and Assessment Checklist (ER Checklist) is to determine whether the
proposed action (scope of work) encompasses the potential for environmental pollution or concern and, if so, to
determine the scope and extent of additional environmental evaluation, mitigation, and monitoring necessary to fulfill
federal U.S. environmental requirements. The ER Checklist is intended to be used by both the Peace Corps
personnel who submit project proposals and the grant selection committee to ensure that environmental
consequences are taken into account before making an award for a proposed activity. The environmental
consequences checklist will assist in determining the potential environmental impact of the proposal.
Include cost information on any environmental mitigation and monitoring in the overall budget proposal. Appropriate
environmental mitigation and monitoring is considered an integral aspect of the overall project activity.
Please provide the following information. This information will assist the grant award committee in making an
environmental impact determination on the proposed activity.
Date:
Volunteer Name:
Location:
Attach a location map as well as site photos in color if possible
Project/Activity
Description:
PC-2105
Type of
Project/Activity:
Baseline
Environmental
Conditions:
Provide site specific environmental conditions. Plant and animal resources, water resource and
condition, human population characteristics, land use, soil, ecosystem condition, air quality. Describe
existing environment at the proposed project site relevant to the scope and potential impact. Include
maps and photos as necessary. Use additional pages as necessary.
A. CHECKLIST FOR ENVIRONMENTAL CONSEQUENCES: Check appropriate column as Yes (Y), Maybe (M),
No (N) or Beneficial (B). Briefly explain Y, M and B checks in next Section, "Explanations". A "Y" response
does not necessarily indicate a significant effect, but rather an issue that requires focused consideration.
Enter Y. M. N. or B
in the column
below
1. Earth Resources
a. grading trenching, or excavation in cubic meters or hectare
b. geologic hazards (faults, landslides, liquefaction, un-engineered fill, etc.)
c. contaminated soils or ground water on the site
d. offsite overburden/waste disposal or borrow pits required in cubic meters or tons
e. loss of high-quality farmlands in hectares
2. Agricultural and Agrochemical
a. impacts of inputs such as seeds and fertilizers
b. impact of production process on human health and environment
c. other adverse impacts
3. Industries
a. impacts of run-off and run-on water
b. impact of farming such as intensification or extensification
c. impact of other factors
4. Air Quality
a. substantial increase in onsite air pollutant emissions (construction/operation)
b. violation of applicable air pollutant emissions or ambient concentration standards
c. substantial increase in vehicle traffic during construction or operation
d. demolition or blasting for construction
PC-2105
PC-2105
PC-2105
Once you have completed all other sections of this application, please print out the following pages, obtain the required
signatures, and return hard copies to post.
1. Liability Form
Fill out the form according to who will be responsible for the project funds: the
Peace Corps Volunteer or the Community. Once complete, print the form.
2. Project Agreement
3. Press Authorization
PC-2105
Directions
If you will be accepting the project funds, print out this form, obtain the necessary signatures, and return
a hard copy to post. If the project funds will be transferred to the community organization, please ensure
the community member accepting the funds signs this document.
Project Title:
Project Number:
Volunteer Name:
Community Partner:
Funding Source:
Grant Amount (USD):
Authorized
Representative of the
Community Partner:
$0.00
By signing below, the Authorized Representative on behalf of the Community Partner and the Peace Corps Volunteer agree
to the following:
TERMS AND CONDITIONS FOR THE COMMUNITY PARTNER AND PEACE CORPS VOLUNTEER
1. Project funds may to be used only for reasonable costs of the Project.
2. The Community Partner and Peace Corps Volunteer are responsible for managing these funds in accordance with the
guidelines applicable to the above referenced funding source and accounting for the use of Project funds.
3. The Community Partner and Peace Corps Volunteer are responsible for obtaining, keeping, recording in the Small Grant
Project Log and submitting to the Peace Corps all original invoices, receipts, or other documentation for all purchases or
other expenditures of Project funds. For all purchases made without the Volunteer present, the Community Partner must
notify the Volunteer, obtain a signed, dated, and witnessed receipt, and record the expenditure in the Small Grant Project
Log.
4. The Community Partner and Peace Corps Volunteer are responsible for returning any unused funds that remain within 30
days of the completion of the Project.
5. Except as agreed to otherwise by the Peace Corps, the Community Partner and Peace Corps Volunteer are liable for any
Project funds disbursed to them that cannot be accounted for or were spent on non-approved costs, lost, or stolen.
6. The Community Partner and Peace Corps Volunteer acknowledge that (a) there will be no additional funding beyond the
Funding Amount above and (b) if this is a Peace Corps Partnership Program (PCPP) project, that funding is not guaranteed.
7. The Community Partner is responsible for obtaining the 25 percent community contribution to the project.
8. The Volunteer and the Peace Corps are not responsible for any activities, expenditures, or liabilities incurred after the
project is closed.
Signature
Date
Date
PC-2105
$0.00
= Local
Currency @
1.00
0.00
Grant Amount
$0.00
= Local
Currency @
1.00
0.00
Third Party
Contribution
$0.00
= Local
Currency @
1.00
0.00
$0.00
= Local
Currency @
1.00
0.00
0%
Obligation Number
IN WITNESS WHEREOF, the community organization named above, the Peace Corps Volunteer, and Peace Corps, pursuant to the terms
and conditions of
By signing this Project Agreement, the community organization and Volunteer agrees to use project funds to support only the activities and
goals described in this project application, and in accordance with the proposed budget. Equipment and goods purchased using funds
awarded will be used to support the objectives of the project and in accordance with the project Application.
(Date)
(Date)
PC-2105
Project Photo Details: For those submitting a PCPP project, PC/headquarters staff can upload Volunteer/Community
photos with each project summary on the donation website. Each project may have one to three photographs associated
with the summary. Pictures of community members, the site of the project, and before pictures are generally the most
compelling for donors. Please use at least the standard quality of pictureno less than 72 pixels/inch. (PC/headquarters
staff may need to crop images.) You must fill out this form for your pictures to be shown on the Peace Corps Website.
I, the undersigned, hereby grant to the Peace Corps a perpetual, worldwide, royalty-free, non-exclusive license to use,
reproduce, or publish for purposes authorized by the Peace Corps Act: my name; the negatives and prints of photographs,
videotapes, and/or other audio or visual recordings of myself; my articles and stories; and any other documents, writings,
statements, recordings, representations, or information I may provide pursuant to and in accordance with the terms of this
Authorization.
In particular, I hereby authorize the Peace Corps to use, reproduce, or publish any or all of the above-listed items and to
make reference to me in connection with these items to promote the Peace Corps using various media and publicity
means, including, but not limited to: websites; books; public service advertising on television and radio stations; television
and radio broadcasts; direct-mail pieces; print advertisements; brochures; flyers; posters; articles; editorials; speeches;
roundtable discussions; radio interviews; and television programs.
I acknowledge that I will receive no compensation from the Peace Corps in consideration of this Authorization or the use of
the above-listed items pursuant to this Authorization.
Volunteer Name
Volunteer Signature
Date
PC-2105
Thank you for completing your small grants application. Please submit this application to
the appropriate staff member at post for project approval.
Labor
1.3.7, Law Enforcement Restructuring, Reform and Operations
Equipment
2.2.3, Local Government and Decentralization
Materials/Supplies 2.2.4, Anti-Corruption Reforms
Land/Venue Rental 2.3.2, Elections and Political Processes
Travel/Per Diem/Foo 2.4.1, Civic Participation
Materials transport 3.1.1, HIV/AIDS
Other
3.1.3, Malaria
2010 3.1.6, Maternal and Child Health
2011 3.1.7, Family Planning and Reproductive Health
2012 3.1.8, Water Supply and Sanitation
2013 3.1.9, Nutrition
2014 3.2.1, Basic Education
2015 3.2.2, Higher Education
2016 3.3.2, Social Services
3.3.3, Social Assistance
4.2.1, Trade and Investment Enabling Environment
4.2.2, Trade and Investment Capacity
4.3.1, Financial Sector Enabling Environment
4.3.2, Financial Sector Capacity
4.5.1, Agriculture Enabling Environment
4.5.2, Agricultural Sector Productivity
4.6.1, Business Enabling Environment
Days
4.6.2, Private Sector Capacity
Weeks
4.6.3, Workforce Development
Months
4.7.3, Strengthen Microenterprise Productivity
4.8.1, Natural Resources and Biodiversity
4.8.2, Clean Productive Environment
5.2.1, Capacity Building, Preparedness and Planning
5.2.2, Disaster Readiness and Mitigation
6.1.1, Cross Cutting
6.6.6, Mozambique USAID Education Funds
9.9.9, PLACE HOLDER TO END THE LIST
1
3
4
5
6
7
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Albania
Armenia
Azerbaijan
Belize
Benin
Bolivia
Botswana
Bulgaria
Burkina Faso
Cambodia
Cameroon
Cape Verde
China
Colombia
Costa Rica
Dominican Rep
Eastern Carib
Ecuador
El Salvador
Ethiopia
Fiji
The Gambia
Georgia
Ghana
Guatemala
Guinea
Guyana
Honduras
Indonesia
Jamaica
Jordan
Kazakhstan
Kenya
Kyrgyz Republ
Lesotho
Liberia
Macedonia
Madagascar
Malawi
Mali
Mexico
Micronesia an
Moldova
Mongolia
Morocco
Mozambique
Namibia
Nepal
Nicaragua
Niger
Panama
Paraguay
Peru
304
305
314
535
680
511
637
313
686
303
694
655
366
514
515
517
538
518
519
663
411
635
242
641
520
675
504
522
497
532
440
306
615
307
632
669
249
684
614
688
510
401
261
309
378
640
697
367
524
683
525
526
527
EMA
EMA
EMA
IAP
AF
IAP
AF
EMA
AF
EMA
AF
AF
EMA
IAP
IAP
IAP
IAP
IAP
IAP
AF
IAP
AF
EMA
AF
IAP
AF
IAP
IAP
EMA
IAP
EMA
EMA
AF
EMA
AF
AF
EMA
AF
AF
AF
IAP
IAP
EMA
EMA
EMA
AF
AF
EMA
IAP
AF
IAP
IAP
IAP
XX
X
Yes
No
N/A
Agriculture
Small Enterprise Development
Education
Environment
Health
Youth
Small Proje
Peace Corp
Volunteer A
Energy Cli
Feed the F
Global Edu
Philippines
Romania
Rwanda
Samoa
Senegal
Sierra Leone
South Africa
Suriname
Swaziland
Tanzania
Thailand
Togo
Tonga
Turkmenistan
Uganda
Ukraine
Vanuatu
Zambia
492
403
696
491
685
636
674
568
645
621
493
693
421
315
617
343
461
611
EMA
EMA
AF
IAP
AF
AF
AF
IAP
AF
AF
IAP
AF
IAP
EMA
AF
EMA
IAP
AF
SP
PP
VA
EC
FF
GEF
Albania
E/E
Armenia
E/E
Azerbaijan
E/E
Benin
AF
Burkina Faso
AF
Cambodia
Asia
Cameroon
AF
Cape Verde
AF
Colombia
LAC
Costa Rica
LAC
Dominican RepublLAC
Eastern Caribbea LAC
Ecuador
LAC
El Salvador
LAC
Ethiopia
AF
Fiji
ANE
Georgia
E/E
Ghana
AF
Guatemala
IAP
Guinea
AF
Jamaica
LAC
Jordan
ME
Kyrgyz Republic Asia
Liberia
AF
Macedonia
E/E
Madagascar
AF
Malawi
AF
Mali
AF
Mexico
LAC
Micronesia
LAC
Moldova
E/E
Mongolia
Asia
Morocco
ME
Mozambique
AF
Nicaragua
LAC
Panama
LAC
Paraguay
LAC
Peru
LAC
Philippines
Asia
Romania
E/E
Rwanda
AF
Senegal
AF
Sierra Leone
AF
Tanzania
AF
The Gambia
AF
Togo
AF
Turkmenistan
Asia
Uganda
AF
Ukraine
E/E
Vanuatu
ANE
Zambia
AF
For SPA
the PAPA referenced above, each acting through its
For VAST
the Memorandum of Understanding referenced abo
For ECPA
the IAA referenced above, each acting through its re
For PCPP
the Manual Section 720 and Manual Section 721, h
For FTF
the PAPA referenced above, each acting through its
Project Agreement is executed pursuant to the Interagency Acquisition Agreement (IAA) between the United States Department of State an
roject Agreement is executed pursuant to the current Small Project Assistance (SPA) IV Participating Agency Program Agreement between
Project Agreement is executed pursuant to the Memorandum of Understanding established between Peace Corps and the PEPFAR initiatit
roject Agreement is executed pursuant to the current Global Food Security Participating Agency Program Agreement between the U.S. Age
Project Agreement is executed purusant to the Peace Corps Manual Section 720 which states that, "Donations to the Partnership Program
above, each acting through its respective duly authorized representative, have caused this SPA Project Agreement to be signed under their
Understanding referenced above, each acting through its respective duly authorized representative, have caused this VAST Project Agreeme
ove, each acting through its respective duly authorized representative, have caused this ECPA Project Agreement to be signed under their r
20 and Manual Section 721, have caused this PCPP Project Agreement to be signed under their respective names and delivered as of this d
above, each acting through its respective duly authorized representative, have caused this FTF Project Agreement to be signed under their
es Department of State and the Peace Corps (PC) signed on August 6, 2010.
ram Agreement between the U.S. Agency for International Development (USAID) and the Peace Corps governing Small Project Assistance
s and the PEPFAR initiatitve.
ent between the U.S. Agency for International Development (USAID) and the Peace Corps (PC) governing Feed the Future Food Security P
the Partnership Program shall be applied exclusively for overseas projects. Donations for projects may be accepted only if they meet the cr
to be signed under their respective names and delivered as of this date and year.
his VAST Project Agreement to be signed under their respective names and delivered as of this date and year.
to be signed under their respective names and delivered as of this date and year.
to be signed under their respective names and delivered as of this date and year.
ed only if they meet the criteria set forth in Manual Section 721, Gifts and Contributions to the Peace Corps."