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DS-4213 Mozambique Reporting Template

ICR 201210-1405-004 · OMB 1405-0208 · Object 35508201.

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File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Title	DS-4213 Mozambique Reporting Template
Author	Terry Zagar
Last Modified By	Calc
File Modified	2012-10-05
File Created	2026-10-07
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Annual Expenditure Analysis- Data Input Instructions
Please complete this Excel template and submit it according to the instructions below.

A manual has been provided to assist with this data request. Please review the template and manual now and cont
Activity Manager (AM)/Program Officer (PO)/Agreement/Contracting Officer's Technical Representative (A/COTR) w
questions.
To ensure uniqueness of file names, please use the following conventions when saving your completed templates:
<OU>_<Agreement ID>_ EP_<Partner Name>_<Reporting Cycle>_<Seq>.xlsx
Where:

<OU> = Two letter international Country code (e.g., VN for Vietnam, TZ for Tanzania, etc.) or Operating Unit (OU) i

<Agreement_ID> = Mechanism Agreement number; the <Agreement ID> is available from the table on the Results
page in PROMIS
E = E for an Expenditure Analysis Template
P = P for template to be attributed to Prime Partner
<Partner_Name> = Name of the organization associated with template results; enter Prime Partner name
<Reporting Cycle> = 'yyyy Expenditures' where yyyy is corresponding Fiscal Year (e.g., 2012 Expenditures)
<Seq> = should consist of two numeric digits as follows:

1st Digit = template number; 1 for 1st template, 2 for 2nd template (if more than one template of this type need
so on up to 9
2nd Digit = template update number; 1 for initial submission; 2 for the next update (if any), and so on up to 9
For example, Seq = ’34’ means the 4th submission of the 3rd template uploaded (3rd in the original sequence)
Note: if a given template fails to upload successfully, its name should be reused in a subsequent upload try after
correction
.xlsx = must be saved as a .xlsx Excel file (not .xls)

Example expenditure analysis (E) template file name :
VN_9740_EP_Columbia University_2012 Expenditures_11.xlsx

Submit the completed template via the PROMIS web-based application and alert your AM/PO/A/COTR of each draft
submission. Respective USG Agency staff (USAID, CDC, DOD, Peace Corps, State) will receive the data from the PRO
application.

Complete the Partner Info page. Be sure to include your organization's contact information. Verify that your inputs
all required information in your submission. Implementing organizations, defined as having a direct financial agreem
a USG Agency, are responsible for collating and submitting all sub-partner data.

For each row on the Program Information- ... and Expenditures- ... information entry tabs, use the drop downs to s
geographical area (sub-national unit, national or above-national) pertaining to each entry row and associated values
in the program area fields for that row of data following the guidance provided (see manual). Each row can have en
one or more of the listed program information columns. Enter results in the correct program information column fo
row. Each row with results MUST specify the sub-national unit in the row in which the results appear. Your trainer w
provide additional guidance on how to apply the categories listed on the form.

The Expenditure Analysis reporting period is 12 months (01 October to 30 September). This period is regardless of w
your organization receives PEPFAR funding.

Please make note of your general comments regarding this mechanism on the Partner Info tab. Please make note o
calculations and comments for the appropriate Program Area heading in the Program Information - Comments and
Expenditures - Comments tabs.
On each Comments tab, please explain the following using the comments fields:
o Explain methods for allocation that differ from the recommended methods in the Expenditure Analysis Manual
o Explain any expenditure values reported less than 10 USD
In general, more information is better.

Prior to submission, please confirm that each of the data quality issues identified on the Data Quality Checks tab ar
resolved.

All USG partners are entitled to report their achievements regardless of overlap with another partner. The informati
provide will help the USG team report more accurate aggregate data.

For the detailed definitions of program and expenditure categories, please refer to the manual provided on the PRO
website.

To help with navigation on the different information entry tabs, notice the Quick Links bar on the left-hand column.
any of the blue hyperlinks to quickly navigate to that entry sub-section. Additionally, on each information entry tab,
hyperlinks to the respective comments field above each entry area. Click a hyperlink to quickly move to the proper t
cell to enter comments for the Program information area; each link reads "Add Comment". Clicking the correspond
next to each comment field will return you to the previous Program Information or Expenditure column.
* NOTE: DO NOT ADD COLUMNS OR ROWS TO THE WORKSHEETS

TYPE

VERSION

Expenditure

2012.00

DS-4213 President's Emergency Plan for AIDS Relief
(PEPFAR) Program Expenditures
Please read Agency Disclosure Notice and
Instructions prior to completing this form

Public reporting burden for this collection of information
is estimated to average 24 hours per response, including
time required for searching existing data sources,
gathering the necessary documentation, providing the
information and/or documents required, and reviewing
the final collection. You do not have to supply this
information unless this collection displays a currently
valid OMB control number. If you have comments on
the accuracy of this burden estimate and/or
recommendations for reducing it, please send them to:
Office of the US Global AIDS Coordinator (S/GAC) U.S.
Department of State, SA-29, 2nd Floor, Washington, DC
20522-2920

OMB No. 1405-xxxx OMB approval expires xx/xx/xxxx
Burden-24 hours

PRIVACY STATEMENT

Personal Information
• This site is only accessible to authorized PROMIS users with an assigned user identifier and associated password. All
transmissions to and from the PROMIS application are protected and secured via SSL encryption.
• PROMIS tracks and associates the following information to each user:
o User name – this information is used to ensure a user is uniquely identified within PROMIS.
o User organization – this information is used to limit access to only those elements of PROMIS data relevant to your org
o User email address – this information is maintained to support user notifications such as a notice for a required passw
change, a notice to review the site terms of use, etc.
o User roles & privileges – this information is used to further limit access to only those PROMIS functional capabilities an
elements of PROMIS data that are relevant to your role within your organization.
o Each user log-on session to include log-in time and log-out time – this information is used to assess the appropriatenes
access to the PROMIS web site.
o Each PROMIS data element entered, updated, or deleted by you in the course of your interactions with PROMIS – this
information is used to track PROMIS data change history, to assess inappropriate PROMIS data changes, and to provide a
identify data that may need to be corrected at a future date.
• The PROMIS hosting services provider also tracks information to support site performance to include:
o The browser used when accessing PROMIS.
o The time and date of each visit to the PROMIS log-in page.
o The PROMIS web pages visited.
o The address of the web site visited immediately prior to visiting the PROMIS web site.
o Any malicious actions against the PROMIS web service.
• Your information will not be disclosed, given, sold, or transferred unless required for law enforcement or otherwise re
law.

o Each user log-on session to include log-in time and log-out time – this information is used to assess the appropriatenes
access to the PROMIS web site.
o Each PROMIS data element entered, updated, or deleted by you in the course of your interactions with PROMIS – this
information is used to track PROMIS data change history, to assess inappropriate PROMIS data changes, and to provide a
identify data that may need to be corrected at a future date.
• The PROMIS hosting services provider also tracks information to support site performance to include:
o The browser used when accessing PROMIS.
o The time and date of each visit to the PROMIS log-in page.
o The PROMIS web pages visited.
o The address of the web site visited immediately prior to visiting the PROMIS web site.
o Any malicious actions against the PROMIS web service.
• Your information will not be disclosed, given, sold, or transferred unless required for law enforcement or otherwise re
law.
• This site is maintained by the U.S. Government and is protected by various provisions of Title 18, U.S. Code. Violations
are subject to criminal prosecution in Federal court.

Use of Cookies
• The PROMIS website maintains both session-based and persistent “cookies” on your browser. PROMIS session-based c
store text information temporarily in your computer’s random access memory (RAM) while you are using PROMIS. When
your web browser, these cookies are removed. PROMIS persistent cookies store information for a longer period and are
identify returning PROMIS users.

HIPAA Privacy Rule Notice
• The PROMIS web site does not collect or maintain individually identifiable Protected Health Information (PHI). While P
Partners may have access to such information from their health service provider Sub-Partners in-Country, PROMIS provi
entry of only aggregated results by pre-defined health Indicator.
• PROMIS maintains no individual identifiers that may be linked to a specific individual or patient.
• The PROMIS web site maintains only aggregate statistical data. In addition to population counts versus Indicator, PROM
maintains sub-counts for certain Indicators by gender (i.e., male or female) and/or age group (e.g., <1 year, 1-5 years, et
the PROMIS database and application is not covered under the HIPAA Privacy Rule.

er and associated password. All
ncryption.

ROMIS.
PROMIS data relevant to your organization.
h as a notice for a required password
PROMIS functional capabilities and

used to assess the appropriateness of your

r interactions with PROMIS – this
MIS data changes, and to provide a means to

mance to include:

e.
law enforcement or otherwise required by

used to assess the appropriateness of your

r interactions with PROMIS – this
MIS data changes, and to provide a means to

mance to include:

e.
law enforcement or otherwise required by

s of Title 18, U.S. Code. Violations of Title 18

browser. PROMIS session-based cookies
while you are using PROMIS. When you close
mation for a longer period and are used to

Health Information (PHI). While PEPFAR
Partners in-Country, PROMIS provides for

or patient.
tion counts versus Indicator, PROMIS only
group (e.g., <1 year, 1-5 years, etc.). Hence

Partner Information
Annual Expenditure Analysis
Partner Background (Complete the areas in light gray below)

Partner Organization Name & Agreement ID: <e.g., ABC Associates: Health Systems Renew (12035 <- 1
Director/Chief of Party:
Telephone:
Cell:
E-mail:
SI Focal Person (if applicable):
Telephone:
Cell:
E-mail:
Financial Focal Person (if applicable):
Telephone:
Cell:
E-mail:
Reporting Information
Submission Date:
Name of Person Submitting Form:
USG Approval (For internal purposes only)
USG Agency:
A/COTR Approval (Name/Date):
SI Officer Approval (Name/Date):
Comments (Provide general comments if needed)

ormation

ysis

Health Systems Renew (12035 <- 1234)>

FY 2012

Information by Program
Area (to be completed by
Partner)
Location

Quick Worksheet
Navigation
Links

FBCTS
CBCTS
PMTCT
HTC
PEP
BS
OVC
SORP-GP
SORP-MARPs
SORP-IDU
SORP-CSW
SORP-MSM
SORP-PLHIV
VMMC
MMT
HSS

Sub-National Unit

Add Comments

FBCTS - Facility-based Care, Treatment, and Support
Clinic Visit: Estimate the average number of times over the year each
patient-type received a clinic visit

Adult Pre-ART Pediatric Prepatients
(15+ ART patients
years)
(< 15 years)

Adult ART
patients
(15+ years)

ent, and Support

Lab Tests: Estimate the average number of times over the year each
er of times over the year each
patient-type received a lab test, including CD4 tests, biochemical panels,
a clinic visit
hematology tests, and viral load assessments

Pediatric ART
patients
(<15 years)

Adult Pre-ART Pediatric Pre-ART
Adult ART
patients
(15+ patients (< 15 patients
(15+
years)
years)
years)

Pediatric ART
patients
(<15 years)

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Program Information - Comments

FBCTS

Program Information - Comments
Please use the space below to provide comments that will aid in interpreting the data.

Return to Results Worksheet

Program Information

Expenditures - Comments

FBCTS

CBCTS

PMTCT

VMMC

HTC

PEP

LAB

OVC

SORP-GP

SORP-MARPs

Surveillance

HSS

Expenditures - Comments
Please use the space below to provide comments that will aid in interpreting the data.