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Screening Level Organization Application Form89535067945000This Screening Level Organization Application Form is a part of the process for identifying organizations for the Genpact Social Impact Fellowship (GSIF) – DIY Model of Engagement. The host organization and its commissioned agency will use the information provided in this form to further assess the credentials and good fit of the organization in line with the objectives of GSIF. I. Basic InformationName of the OrganizationLegal Name (if different from above)Year of EstablishmentFull Address(India Headquarter)City/District and StatePin codeLandline No.Website URLPerson Filling the FormDesignationCommunication Email Alternate EmailMobile No. Alternate Mobile No.II. Due DiligenceYou are registered in India as: (Please click on the checkbox to select)?Section 8 or Section 25 organization?Society?Trust?Others (please specify) …………………Please select the ones that your organization has: (Please click on the checkbox to select) (All documents to be attached during submission)Mandatory?Registration Certificate?80 G (for 50% tax benefits)?12 A (Tax exemption for NGO income)?Past three years audit reportsNon-mandatory?FCRA (For international funding) 27527256350Provide FCRA Number00Provide FCRA Number?35 AC (for 100% tax benefits)?Past three years’ annual reportsPlease mention if there is any litigation history of the organization:III. Organizational ProfileBriefly explain your organization’s origin and work history up to year 2020 (Max.150 wordsPlease elaborate the Problem statement, i.e., the core problem(s) being addressed by the organization through development projects. (Max 120 words)Please provide the organization’s Budget Details in INR (Cr.) as per the table below: FY 19-20FY 20-21 (Provide provisional/ unaudited number as applicable)FY 21-22 (Estimated)FY 22-23(Estimated)FY 23-24(Estimated)Organizational Income (in INR Cr.)Organizational Expenditure (in INR Cr.)What have been the key year-wise outcome and end beneficiary impact of the organization in the last 3 years, also mention the expected end beneficiary impactYearNumber of end beneficiary impactedOutcomesFY 18-19FY 19-20FY 20-21Projected end beneficiary impact numberExpected OutcomesFY 21-22FY 22-23FY 23-24Please give names of city/district and states where you have project offices in India:City/DistrictState1 2345In the table below, please mention the number of full-time employees and Other/part time employees in the organization, as on 30 Jan 2021LevelNo. of EmployeesFull-timeOthers (Volunteers, Part-time)Top ManagementProgram Lead Team (Program Director, Program/Project Manager)Field Team (staff)Admin, finance and IT teamTotal Employees in the organizationPlease mark the thematic area in which you have projects and mention sub-theme area with respect to the selected themes:ThemeMark Yes/NoSub-theme (specific/ focus area of work)Years of ExperienceEducationEmployability and SkillsHealthcareLivelihood DevelopmentWomen EmpowermentOther (please specify)Please provide the funding details of the organization. (Committed funding and expected funding)YearCommitted Funding (in INR Cr.)Funding Source(s)Expected funding (in INR Cr.)(Expected) Funding Source(s)FY 21-22FY 22-23FY 23-24Please mention the potential risk (if any) for the organization. For example: Impact of COVID, FCRA Regulation change etc. (Feel free to add more rows)CategoryScale of Impact (High/Medium/ Low)DetailsIV. IT and AdministrationIndicate with Yes or No if the organization uses any IT tools for the following, to efficiently manage operations, functions and projects.IT Tool used forYes/NoIf Yes, mention which one?HRMCRMMISFinanceERPEmailOther SoftwareV. Proposed Project Details MIS is at what level?Organization Level?Program/ Project LevelIf, required at project/ Program level, please provide the below details Name of program/projectProject Starting DateProject Ending DateCurrent Project Status (Ongoing, Proposed, Implemented- Replicable)Total Project Fund (in INR Cr.)Sources of Fund (Donor Organizations)Project Office AddressProject District; State(Can type multiple locations, if required)Please give an overview of the project to help us understand what it is all about, outlining the need of the project. (Max. 180 words)(Quote any baseline survey, need assessment or research that has been done to identify problems and solution roadmap) What are the key Impact indicators of the project?)(What is it that you are trying to achieve through this project. Please be very specific about the objectives)Please elaborate the implementation plan of the project.What have been the key year-wise outcomes and end beneficiary impact of the projects in the last 3 years (at most) of implementation? Also mention the expected end beneficiary impact of the project. Please share the project log frame in the attachments.YearNumber of end beneficiary impactedOutcomesFY 18-19FY 19-20FY 20-21Projected end beneficiary impact numberExpected OutcomesFY 21-22FY 22-23FY 23-24Scope of Engagement- MIS / M & EWith respect to the GSIF Project, please provide details as per the table below:Write your answer below:Which project delivery cycle would you prefer to work with GSIF in?Aug – Dec 2021Jan – May 2022Scope of MIS engagement (highlight/choose one option)MIS Reporting systemMIS Processes documentation with Tech implementationM & E systemWhat is the problem that the organization is facing with the current MIS? How is the current MIS structured?Please explain the current platform used for MIS Online/offline (tech tool, Excel, Google sheets etc.)Your Data Consolidation Platform? Is it on excel?Data governance to ensure data quality and security?How is your MIS linked to reporting, do you use any tool to publish reports? Please share the details along with a reporting samplePlease explain your data collection methodDo you have a set template for data collection? Is it a pen & paper or any tech-based platform (please share details)?Do you collect data in Hindi or English or in any other language? Please mention the language. Is the data collection language consistent?How frequent do you publish the reports? Are these reports audited or are these for internal reporting purpose?How do you plan to sustain the MIS solution proposed by the GSIF, once GSIF exits after 3 years? (Do you foresee any challenges? – what are your mitigation plan? –e.g.- can you allocate fund for AMC, have more than one resource trained/ oriented by GSIF etc.…How many resources work on MIS? Are they full time employee/ shared resources? Please share details.How much time does the entire reporting system take currently?How do you conduct monitoring and evaluation for the project? Do you have a third party (deployed by funder/ self) that will be engaged for this? If yes, please share the report.Is the organization willing to work on virtual mode, highlight if any, infrastructure challenges- such as internet, etc.Would you be willing to use excel based solution for reporting, without any integration with any other platform?Are you willing to assign a dedicated resource from the MIS function to work with GSIF team for next 6 months? The resource will need to spend 20 hrs. a week with the GSIF team. Do you agree to commit to a 3 year engagement period with GSIF for reporting on the impact and challenges of the MIS deployed? ?Yes?NoWhat frequency of reporting would be preferred for the same??Quarterly?Half-yearly?YearlyPlease go over the JD below before nominating a person.Share the details (name, experience-overall and in current role, phone no.)We would like to briefly interact with the resource to check fitmentJD of MIS resource from NPO –Mandatory : Can allot 20 hrs. a week, for 6 months Able to read/ write/ speak in English as our training module will be in EnglishGood to have Experienced / has fair knowledge on MIS Has been in the org for > 3 yrs - Understands vision/ mission and programs of the orgGood communication skillsFamiliarity with technology esp. MS officeWilling to work and learn as per the GSIF methodologyAbility to deal with stakeholder / leaders / ability to take decision and convenience other to provide dataPlease fill the given table with success parameters/ key indicators, related impact and expected impact details of the associated projectKey Indicators (max 4)Impact StatusExpected Impact (Projected)2021-222022-232023-24What are the key risk factors for achieving the planned outcomes and impacts of the project and how do these factors affect the project? (Max. 180 words)What are the things that can be done/planned to minimize or mitigate the impact of above-mentioned risk factors? (Max. 180 words)Declaration by the OrganizationWe as an organization declare that all the information provided above is true and correct. We understand that this information will be used to evaluate our organization credential and future association for Genpact Social Impact Program. If at any stage, the host organization or agency appointed by them, asks for any supporting document for the information mentioned in this form, we shall. Furnish that as per the allotted timelines. Authorized signatoryName:Designation: Date: Terms and conditionsWillingness to share data/information, as required and necessary for delivery of the project. Genpact has restrictions on access to certain client shared drives hence information may need to be shared over email. We have a confidentiality clause in the MoU to protect your data.The applicant organization is willingly submitting this form and there is no application fee or processing fee being charged for the same.The host organization and its commissioned agency are not abided to disclose the evaluation process and decisions, thereafter, to the applicant organizationThe applicant organization is aware that there is no direct funding or grant involved in this fellowship program and any decision for financial support/grant in future is subject to the host organization’s discretion. The submission of this form does not guarantee shortlisting for the GSIF.**End**Annexure ChecklistSl. noDocumentSubmissionYes/No/ NA1Registration Certificate280 G (for 50% tax benefits)335 AC (for 100% tax benefits)412 A (Tax exemption for NGO income)5FCRA (For international funding)6Past 3 years’ audit reports7Past 3 years’ organization annual report8Project LFA9Reporting Sample (audited/ third part reports, Donor/ internal reports)10Nominated Resource JDOnce completed, please send it to prachi@ and mark CC to pooja@Make sure you attach all documents required in the email. Keep the subject as ‘GSIF Completed Screening Form and Attachments [Organization Name].’Deadline: 15th March 2021 ................
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