Download:
pdf |
pdfOMB Approval No.: 0412-0011
Exp. Date: 06/30/2009
AMERICAN SCHOOLS AND HOSPITALS ABROAD (ASHA)
Application for Assistance
This application is for use by private non-profit U.S. organizations requesting grant assistance for overseas institutions under
Section 214 of the Foreign Assistance Act, as amended. “Applicant” refers to the United States Organization (USO), the
sponsor of the Overseas Institution (OSI). Applications must be postmarked by June 30th for consideration during the
following fiscal year beginning October 1st.
The information provided about the USO, the OSI, and the grant proposal should be thorough and concise using a Times
New Roman 10-point font size. Use examples to support general statements.
Finally, this application is comprised of four sections. They are: Section 1 – General Information; Section 2 – the Project;
Section 3 – the United States Organization (USO); and Section 4 – the Overseas Institution (OSI).
Please feel free to use the Continuation Page at the end of the application should you require additional space in any of the
sections. We also ask that you label and attach each continuation page appropriately.
The submission of the application package requires completed duplicate copies of the following: the application, Lobbying
Activities and Terrorist Financing certifications (found at www.usaid.gov/asha), Articles of Incorporation, By-Laws, and proof
of the U.S. Internal Revenue Service’s recognition of tax exempt status, financial statements (within the past two years) of
both the USO and OSI prepared by independent public accountant(s) indicating the organizations’ conformity with U.S.
Government accounting principles. (OMB Circular A-133)
Mail application (postmarked by June 30th) to:
The United States Agency for International Development
American Schools and Hospitals Abroad
1300 Pennsylvania Avenue, NW
Washington, DC 20523
The public reporting burden for the collection of information is estimated to average 12 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. USAID may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. All financial data submitted will not be
released without prior consent from applicant. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to:
U.S. Agency for International Development
American Schools and Hospitals Abroad
1300 Pennsylvania Avenue, NW
Washington, D.C. 20523
AID 1010-2 (06/2009)
Page 1 of 25
Section 1. General Information
1.1. United States Organization (USO) Information:
Name:
Address 1:
Address 2:
City:
Phone:
Fax Number:
Email:
Website:
State:
Zip:
For Fiscal Year:
Amount Requested from ASHA:
Type of organization:
Non-Profit Organization
Other
USO is the OSI’s:
OSI name:
Date USO’s sponsorship of OSI
commenced:
Founder
Date organization established:
Sponsor
Jurisdiction of USO incorporation:
OSI country:
IRS exemption:
IRS exemption number:
Date IRS exemption issued:
Code:
1.2. USO Authorized Representative:
First Name:
Last Name:
Title:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Email:
Website:
1.3. Overseas Institution (OSI) Information:
Name:
Address 1:
Address 2:
City:
State/Province:
Postal Code:
Country:
Phone:
Email:
Website:
Date Established:
Chartered By:
Accredited By:
1.4. Information on the Principal Officer of the OSI:
First Name:
Title:
Address 1:
Address 2:
City:
State/Province:
Postal Code:
Country:
Phone:
Email:
Website:
AID 1010-2 (06/2009)
Last Name:
Page 2 of 25
1.5. DATA SUMMARY SHEET IN USD
Year of request:
Name of the Overseas Institution:
Name of the U.S. Sponsor:
Overseas Institution’s fiscal year:
Month fiscal year begins:
INCOME
AMOUNT
Month fiscal year ends:
%
EXPENSES
Tuition/Fees
%
Faculty/Medical Staff
%
Private Gifts and Grants from
%
Administrative Staff
%
U.S. Sources
%
Operation/Maintenance/Overhead
%
Host Country Sources
%
Auxiliary Enterprises
%
International Sources
%
Students’ Services/Activities
%
%
Student-aid/Scholarships
%
ASHA
%
Outreach/Extension, etc.
%
Other USAID
%
Plant improvement
%
Other U.S. Government
%
Debt Service
%
Host Country Government
%
Cash Transfers
%
Other Donor Government
%
Publicity/Fundraising
%
International Agencies
%
Other (specify) ______________
%
%
%
Endowment Income
%
%
Other Sources
%
Government Grants/Contracts
Auxiliary Enterprises
(use continuation
page)
(use continuation page)
$0.00
TOTAL INCOME:
ENDOWMENT
TOTAL EXPENSES:
$0.00
0%
BENEFICIARIES
Market Value
Students:
% Return on Value
PHYSICAL PLANT
%
%
0%
Year
AMOUNT
No. Full-Time Degree Earning
%
No. Part-Time Degree Earning
Year
No. Non-Degree
Replacement Value
Date of Last Assessment
TOTAL: EACH
PRIVATE FUNDRAISING
Year
Contributions
Individuals
Foundations/Corporations
Alumni
number
0
Total Donors
Alumni as % Value of Private Gifts
0
Patients
amount
Inpatients (annually)
Outpatients (annually)
TOTAL: EACH
$0.00
(
)
0
Others benefiting from outreach/
activities not included in the above
SUMMARY of USE of REQUESTED FUNDS: A grant of U.S. Dollars $___________ is requested on behalf of the overseas
institution to (in 25 words or less, state the purpose and major activity(ies))
AID 1010-2 (06/2009)
Page 3 of 25
Section 2. The Project
Program Criteria: A USO requesting capital construction assistance must provide information sufficient to permit a
firm estimate of the total cost to the U.S. Government of the construction for which assistance is requested. Such
USO must also provide information and assurance with respect to rights to the land on which construction is
planned.
Program Criteria: To help achieve the objectives of the Foreign Assistance Act and ensure that the American
Schools and Hospitals Abroad program is as geographically balanced as possible, special consideration will be
given to applications for institutions that increase the geographical distribution of the program and contribute to
economic and social progress of areas that are the focus of U.S.A.I.D.’s development efforts.
Briefly describe the purpose and justification of the project.
2.1. Describe the project (if request is for commodities include list of commodities requested. If for construction, include
detailed construction budget. Use continuation page if necessary):
How does the project relate to the OSI’s longer-term strategy?
AID 1010-2 (06/2009)
Page 4 of 25
2.2. How does the project promote American ideas and practices?
2.3. Justify the project in terms of:
Need:
Benefits and expected results (Quantify the number of trainees, people served, research outputs,
beneficiaries/participants):
AID 1010-2 (06/2009)
Page 5 of 25
2.4. Project Management:
How will the project be implemented? Who will be the General Contractor? Who will supervise the project? What is the
timeline (i.e., number of months to start and complete)?
How will the project be sustained (recurring costs, maintenance, etc.)? Are there trained staff available to maintain
equipment?
2.5. Total project budget (broken down by major elements and represented in USD):
Project type
ASHA
USO
OSI
Other Sources
(Please list and
specify other
sources in the
space provided
below.)
Total
$0.00
Professional Services:
$0.00
Construction:
$0.00
Renovation:
$0.00
Commodities:
$0.00
Vehicles:
$0.00
Program Support:
$0.00
$0.00
$0.00
$0.00
Total:
Please specify and list other sources:
AID 1010-2 (06/2009)
Page 6 of 25
FOR CONSTRUCTION AND RENOVATION PROJECTS ONLY (Sections 2.6, 2.7, 2.8)
(Generally ASHA funds will not be approved to add floors or stories to the top of existing structures.)
2.6. Architectural Engineering and Planning.
Extent of architectural-engineering (A/E) planning undertaken to date:
Name(s) and address(es) of A/E firm(s) or consultant(s): Include with this application initial (A/E) plans and cost
estimates, and certification of land rights and permits, as applicable.
2.7. Status of land (please check the box that applies):
Land Owned
Land Leased, if so please answer the following:
How long?
Date of Expiration
2.8. Host Country approval
Has the Host Country Government approved the OSI’s construction plans?
Yes
No
If Yes, Specify:
Name and Title:
Date of Approval:
Ministry or Entity:
Indicate any pending approval needed:
AID 1010-2 (06/2009)
Page 7 of 25
Section 3. United States Organization (USO)
Program Criteria: The applicant should be a non-profit U.S. organization which either founded or sponsors the
Overseas Institution (OSI) for which assistance is sought. Preferably, the applicant should be tax-exempted
under Section 501(c)(3) of the Internal Revenue Code of 1954. The applicant must demonstrate a continuing
supportive relationship with the OSI. Evidence of this should be the provision of financial and management
support for the OSI.
This section seeks to gather information about the USO’s policies and administration of, and fundraising for, the OSI.
Information such as: USO’s Board of Trustees, Governors, and administrative office.
3.1. Provide the names, titles, and citizenship of USO’s board(s) of trustees and principal officers:
AID 1010-2 (06/2009)
Page 8 of 25
3.2. Brief biographies of the principal officers of the USO board. Provide brief (25 words or less) mission statement/objective.
Highlight only relevant background/experience (one paragraph per biography). Do not exceed space provided:
3.3. Relationship of the USO with the OSI
Number of paid staff in the U.S.
Full-time:
Percentage of U.S. staff time
devoted to the OSI:
Approximate annual person hours of
volunteer time spent on OSI’s work:
%
Part-time:
AID 1010-2 (06/2009)
Page 9 of 25
3.4. Describe the role of the USO in the following activities of the OSI.
Provide examples of the USO’s specific involvement with the OSI.
Policy setting and management oversight:
Curriculum and program development assistance to the OSI:
Key management and administrative staffing used to support the OSI:
Other program support and technical support provided to the OSI:
AID 1010-2 (06/2009)
Page 10 of 25
3.5. USO’s financial and in-kind contribution to the OSI. Specify any direct financial contribution to the OSI in each
of the past three years. Include resources other than USO direct contribution mobilized on behalf of the OSI. Describe
recent, current, and planned strategic partnership efforts (alumni, alliances with foundations, corporations, universities
and others) by the USO and the OSI in the United States, in the host country, and in other areas. Describe how
fundraising efforts are managed and indicate how much has been spent on such efforts in each of the past three years.
Year:
Contribution amount (Please reflect in US Dollars):
Cash:
In-kind:
Estimated cost for fundraising efforts:
Funds mobilized from other sources (include amount(s) and name(s) of donor(s)):
Strategic Partnerships:
Year:
Contribution amount (Please reflect in US Dollars):
In-kind:
Cash:
Estimated cost for fundraising efforts:
Funds mobilized from other sources (include amount(s) and name(s) of donor(s)):
Strategic Partnerships:
Year:
Contribution amount (Please reflect in US Dollars):
Cash:
In-kind:
Estimated cost for fundraising efforts:
Funds mobilized from other sources (include amount(s) and name(s) of donor(s)):
Strategic Partnerships:
AID 1010-2 (06/2009)
Page 11 of 25
3.6. Prior ASHA Grants (Last 3 Years):
Year received:
Purpose:
Year received:
Purpose:
Year received:
Purpose:
3.7. Summary of USO’s Most Recent Financial Status:
USO Budget in USD
Annual budget of the U.S. office:
USO Financial Statement
USO Balance sheet for year ending:
Current assets:
Endowments:
Fixed assets:
Other assets:
Total assets:
Current liabilities:
Long term liabilities:
Net assets:
Total liabilities and net assets:
USO Income Statement
USO income statement for year ending:
Tuition/fee revenues:
Private grants and donations – U.S.:
Private grants and donations – Other:
Public/government grant revenue – U.S.:
Public/government grant revenue – Other:
Other income:
Total revenue:
Direct expenses:
Administrative expenses:
Depreciation expenses:
Other expenses:
Total expenses:
Gain/(Loss):
AID 1010-2 (06/2009)
Page 12 of 25
Section 4. Overseas Institution (OSI)
Program Criteria: An instruction program must serve the secondary or higher level and must reflect American
educational ideas and practices (education at the elementary school level will not be supported) A school offering
a broad-based academic program must include instruction on the history, geography, political science, cultural
institutions, or economics of the United States. English should be used in instruction or taught as a second
language. However, the foregoing subject matters and language requirements need not apply to a school offering
only a specialized course.
Program Criteria: An existing OSI must demonstrate competence in professional skills and must exhibit sound
management and financial practices. A USO for a new OSI must demonstrate the ability to achieve professional
competence and to operate in accordance with sound management and financial practices.
4.1. OSI information:
Provide the name, titles, and citizenship of the OSI’s board(s) of trustees and principal officers:
AID 1010-2 (06/2009)
Page 13 of 25
4.2. History of the OSI:
4.3. Major accomplishments:
AID 1010-2 (06/2009)
Page 14 of 25
4.4. Current objectives:
4.5. Curriculum:
As applicable, insert number of:
Departments:
English is:
Prime Language of Instruction
Courses:
Second Language of Instruction
Majors:
Taught as a Second Language
Describe levels of instruction and provide details on the curriculum.
For secondary schools, list courses offered by year.
For colleges and universities, list majors offered and degrees given.
For special courses describe relevant non-degree courses offered.
For hospital centers, describe the scope of training and/or research.
For all institutions briefly describe any special education or training program that may be offered outside the
institution.
AID 1010-2 (06/2009)
Page 15 of 25
Program Criteria: Institutions are expected to reflect favorably upon and to increase understanding of the United States.
4.6. How does the OSI serve to demonstrate and promote ideas and practices of the United States in education
and/or medicine? Be specific about how American techniques and methods are adopted to serve needs and describe
the institution’s role in improving educational and/or medical standards:
AID 1010-2 (06/2009)
Page 16 of 25
Program Criteria: The faculty and staff of a school or a hospital center should include a significant number of U.S.
citizens or other persons trained in U.S. institutions who are in residence and teaching at the school or hospital on
either a full-time or part-time basis.
4.7. OSI’s Staff:
Total Number
of Persons
Admin
Full-time
Admin
Part-time
Faculty
Full-time
Faculty
Part-time
Med Staff
Full-time
Med Staff
Part-time
Maint/
Clerical
TOTAL
U.S. Citizens:
0
Citizens of
Host Country:
0
Citizens of
Other
Countries:
0
0
0
0
0
0
0
0
Admin
Full-time
Admin
Part-time
Faculty
Full-time
Faculty
Part-time
Med Staff
Full-time
Med Staff
Part-time
Maint/
Clerical
Total Number:
Academic
Background
TOTAL
U.S. Degrees:
0
U.S. Trained:
0
Other:
0
Briefly describe the criteria used for the selection of faculty and staff:
AID 1010-2 (06/2009)
Page 17 of 25
Program Criteria – The majority of the users of any institution, e.g. students or patients, must be citizens of
countries other than the U.S.
4.8. Enrollment, selection and cost information (secondary and higher levels only, including hospitals)
Enrollment
Period
Degree/Diploma
Students FullTime
Degree/Diploma
Non-Degree/
Non-Degree/
Students Part- Diploma Students Diploma Students
Time
Full-Time
Part-Time
Student to Faculty
Ratio Ex. (10.1)
Prior Year:
Current Year:
Next Year:
Percentage of students that are not U.S. Citizens: Current year
%
Prior year
%
For Degree/Diploma Students, indicate the number of male and female students over the last two years:
Male students:
Female students:
Nationalities represented in Student Body: Female:
Male:
Percentage or number of students receiving scholarships for current year:
Annual costs and charges for one Full-Time
student (for the year:
)
Student
OSI
Totals
Tuition:
$0.00
Room and board:
$0.00
Other fees:
$0.00
Total per Student:
$0.00
$0.00
Average aid amount:
Total student aid or scholarship assistance provided (indicate percentage of student aid or scholarship funds by
source).
From USO:
%
Host Country Government:
%
From OSI:
%
Other sources:
%
AID 1010-2 (06/2009)
Page 18 of 25
Program Criteria – The institution must be open to all persons regardless of race, religion, sex, color or national
origin. (The foregoing shall not be construed to require enrollment of students of both sexes at an educational
institution enrolling either boys or girls only.) Direct assistance may not be used to support any inherently
religious activity such as worship, religious instruction or proselytization.
4.9. Selection – Describe briefly the methods used for selection of students and award of scholarships. Include efforts
taken to ensure that the institution is open to all persons without regard to race, color, or national origin:
4.10. Physical Plant – Describe the institution’s physical plant, including real estate, the number of buildings, and their
use. Indicate any facility or land leased – rather than owned – and explain.
Estimated market
value:
AID 1010-2 (06/2009)
Estimated
replacement value:
Annual income:
Annual operating
costs:
For the year:
Page 19 of 25
FOR MEDICAL FACILITIES ONLY (Sections 4.11, 4.12, 4.13, 4.14)
4.11. If more than one facility, indicate: ‘1’ as the main hospital and ‘2’ as the secondary facility or facilities.
Average Monthly number of In-patients: Average Monthly number of OutPersons served by Outreach Program:
patients:
Number of beds authorized:
Rate(s) of
occupancy:
Actual cost per bed per
day:
Average length of stay (in
days):
Main:
Secondary:
Program criteria – A hospital center, in addition to being a treatment facility, must be involved in medical education and
research. Programs for post-graduate training of staff in the United States and programs for the exchange of personnel
with American institutions will be regarded as evidence of ability to demonstrate American ideas and practices in
medicine.
4.12. Describe medical facility’s rate structure and income level. As appropriate, describe medical facility or auxiliary
activities providing additional income to the institution.
AID 1010-2 (06/2009)
Page 20 of 25
4.13. Describe managerial structure. (Note any special review committees. Do private physicians have hospital
privileges? If so, indicate what kind)
4.14. Describe the institution’s major areas and types of research and/or training (formal and non-formal
programs.) (e.g. epidemiological, survey, operational research, and other activities. Note the number of persons involved
and uses made of research results.)
AID 1010-2 (06/2009)
Page 21 of 25
Program Criteria – The OSI must be located outside the U.S. and should not be under the control of management
of a government or any of its agencies. The receipt of financial or other assistance from a government agency or
the observance of national education or medical standards required by the host country does not in itself mean
that the OSI is “under the control or management “of such government.
4.15. U.S. assistance.
Is the OSI benefiting from any USAID or other U.S. Government assistance?
NO
YES
(Indicate amount and type for the past two years.)
Year:
Amount:
Description:
Year:
Amount:
Description:
4.16. Specify any assistance to the OSI from the Host Country Government or para-statal entity(ies) in the past
two years. Describe services performed for or on behalf of those entities for which the OSI was reimbursed.
Year:
Amount:
Description:
Year:
Amount:
Description:
AID 1010-2 (06/2009)
Page 22 of 25
4.17. Summary of OSI’s Financial Status:
OSI Budget:
Annual budget of the OSI:
OSI Financial Statement:
OSI Balance sheet for year ending:
Current assets:
Endowments:
Fixed assets:
Other assets:
Total assets:
Current liabilities:
Long term liabilities:
Net assets:
Total liabilities and net assets:
OSI Income Statement:
OSI income statement for year ending:
Tuition/fee revenues:
Private grants and donations – U.S.:
Private grants and donations – Other:
Public/government grant revenue – U.S.:
Public/government grant revenue – Other:
Other income:
Total revenue:
Direct expenses:
Administrative expenses:
Depreciation expenses:
Other expenses:
Total expenses:
Gain/(Loss):
4.18. Financial Information Pertaining to the OSI:
Endowments – Indicate size of USO’s and/or OSI’s endowment (e.g. amount of income earned and percentage return on
investment, etc.) Also, explain extent to which endowment is restricted and for what purposes.
a. USO Endowments
b. OSI Endowments
Significant liabilities – Describe significant debt on financial statements and payment terms.
AID 1010-2 (06/2009)
Page 23 of 25
CERTIFICATION
The undersigned, as an official of the applicant organization, certifies that the information in this application is complete
and free from misrepresentation and does not knowingly omit any material fact to the information requested.
Name and Title of Person Signing:
Signature:
Date
NOTE: Failure to provide all requested information in this application form may be cause for rejection.
Review the checklist to ensure the application is satisfactorily completed and that all required certifications
and attachments are included.
AID 1010-2 (06/2009)
Page 24 of 25
Add Page
CONTINUATION PAGE
Name of Section:
Section Number:
Section to be continued as follows:
AID 1010-2 (06/2009)
Continuation Page
| File Type | application/pdf |
| File Title | ASHA Grant Application 2007 |
| Author | Raissa Remandaban |
| File Modified | 2009-06-19 |
| File Created | 2007-03-16 |