+---+-------------------------------+-----------------------------------+
| * |                               |                                   |
| * |                               |                                   |
| U |                               |                                   |
| S |                               |                                   |
| A |                               |                                   |
| I |                               |                                   |
| D |                               |                                   |
| * |                               |                                   |
| * |                               |                                   |
|   |                               |                                   |
| * |                               |                                   |
| * |                               |                                   |
| D |                               |                                   |
| i |                               |                                   |
| v |                               |                                   |
| i |                               |                                   |
| s |                               |                                   |
| i |                               |                                   |
| o |                               |                                   |
| n |                               |                                   |
| o |                               |                                   |
| f |                               |                                   |
| A |                               |                                   |
| m |                               |                                   |
| e |                               |                                   |
| r |                               |                                   |
| i |                               |                                   |
| c |                               |                                   |
| a |                               |                                   |
| n |                               |                                   |
| S |                               |                                   |
| c |                               |                                   |
| h |                               |                                   |
| o |                               |                                   |
| o |                               |                                   |
| l |                               |                                   |
| s |                               |                                   |
| a |                               |                                   |
| n |                               |                                   |
| d |                               |                                   |
| H |                               |                                   |
| o |                               |                                   |
| s |                               |                                   |
| p |                               |                                   |
| i |                               |                                   |
| t |                               |                                   |
| a |                               |                                   |
| l |                               |                                   |
| s |                               |                                   |
| A |                               |                                   |
| b |                               |                                   |
| r |                               |                                   |
| o |                               |                                   |
| a |                               |                                   |
| d |                               |                                   |
| * |                               |                                   |
| * |                               |                                   |
|   |                               |                                   |
| * |                               |                                   |
| * |                               |                                   |
| F |                               |                                   |
| i |                               |                                   |
| n |                               |                                   |
| a |                               |                                   |
| l |                               |                                   |
| P |                               |                                   |
| r |                               |                                   |
| o |                               |                                   |
| j |                               |                                   |
| e |                               |                                   |
| c |                               |                                   |
| t |                               |                                   |
| R |                               |                                   |
| e |                               |                                   |
| p |                               |                                   |
| o |                               |                                   |
| r |                               |                                   |
| t |                               |                                   |
| a |                               |                                   |
| n |                               |                                   |
| d |                               |                                   |
| E |                               |                                   |
| v |                               |                                   |
| a |                               |                                   |
| l |                               |                                   |
| u |                               |                                   |
| a |                               |                                   |
| t |                               |                                   |
| i |                               |                                   |
| o |                               |                                   |
| n |                               |                                   |
| * |                               |                                   |
| * |                               |                                   |
+---+-------------------------------+-----------------------------------+
| G |                               |                                   |
| r |                               |                                   |
| a |                               |                                   |
| n |                               |                                   |
| t |                               |                                   |
| e |                               |                                   |
| e |                               |                                   |
| ' |                               |                                   |
| s |                               |                                   |
| N |                               |                                   |
| a |                               |                                   |
| m |                               |                                   |
| e |                               |                                   |
| [ |                               |                                   |
| : |                               |                                   |
| ] |                               |                                   |
| { |                               |                                   |
| . |                               |                                   |
| s |                               |                                   |
| m |                               |                                   |
| a |                               |                                   |
| l |                               |                                   |
| l |                               |                                   |
| c |                               |                                   |
| a |                               |                                   |
| p |                               |                                   |
| s |                               |                                   |
| } |                               |                                   |
+---+-------------------------------+-----------------------------------+
| U |                               | Period of Performance             |
| S |                               |                                   |
| A |                               | From \_\_/\_\_/\_\_\_\_ to        |
| I |                               | \_\_/\_\_/\_\_\_\_                |
| D |                               |                                   |
| A |                               |                                   |
| w |                               |                                   |
| a |                               |                                   |
| r |                               |                                   |
| d |                               |                                   |
| N |                               |                                   |
| u |                               |                                   |
| m |                               |                                   |
| b |                               |                                   |
| e |                               |                                   |
| r |                               |                                   |
| : |                               |                                   |
| H |                               |                                   |
| S |                               |                                   |
| H |                               |                                   |
| - |                               |                                   |
| G |                               |                                   |
| - |                               |                                   |
| 0 |                               |                                   |
| 0 |                               |                                   |
| - |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| - |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
|   |                               |                                   |
| A |                               |                                   |
| S |                               |                                   |
| H |                               |                                   |
| A |                               |                                   |
| G |                               |                                   |
| r |                               |                                   |
| a |                               |                                   |
| n |                               |                                   |
| t |                               |                                   |
| N |                               |                                   |
| u |                               |                                   |
| m |                               |                                   |
| b |                               |                                   |
| e |                               |                                   |
| r |                               |                                   |
| : |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| - |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
| \ |                               |                                   |
| _ |                               |                                   |
+---+-------------------------------+-----------------------------------+
| # |                               |                                   |
|   |                               |                                   |
| P |                               |                                   |
| R |                               |                                   |
| O |                               |                                   |
| J |                               |                                   |
| E |                               |                                   |
| C |                               |                                   |
| T |                               |                                   |
|   |                               |                                   |
| R |                               |                                   |
| E |                               |                                   |
| P |                               |                                   |
| O |                               |                                   |
| R |                               |                                   |
| T |                               |                                   |
+---+-------------------------------+-----------------------------------+
| 1 | Original purpose of Grant     |                                   |
|   | (per Grant Agreement)         |                                   |
+---+-------------------------------+-----------------------------------+
|   |                               |                                   |
+---+-------------------------------+-----------------------------------+
| 2 | Final use of funds (if        |                                   |
|   | different from original       |                                   |
|   | purpose)                      |                                   |
+---+-------------------------------+-----------------------------------+
|   |                               |                                   |
+---+-------------------------------+-----------------------------------+
| 3 | Reasons for changes (please,  |                                   |
|   | make reference to ASHA        |                                   |
|   | approvals)                    |                                   |
+---+-------------------------------+-----------------------------------+
|   |                               |                                   |
+---+-------------------------------+-----------------------------------+

+---+-------------------------------------------------+-------+--------+
| # |                                                 |       |        |
| # |                                                 |       |        |
|   |                                                 |       |        |
| P |                                                 |       |        |
| R |                                                 |       |        |
| O |                                                 |       |        |
| J |                                                 |       |        |
| E |                                                 |       |        |
| C |                                                 |       |        |
| T |                                                 |       |        |
|   |                                                 |       |        |
| R |                                                 |       |        |
| E |                                                 |       |        |
| P |                                                 |       |        |
| O |                                                 |       |        |
| R |                                                 |       |        |
| T |                                                 |       |        |
|   |                                                 |       |        |
| * |                                                 |       |        |
| ( |                                                 |       |        |
| c |                                                 |       |        |
| o |                                                 |       |        |
| n |                                                 |       |        |
| t |                                                 |       |        |
| i |                                                 |       |        |
| n |                                                 |       |        |
| u |                                                 |       |        |
| e |                                                 |       |        |
| d |                                                 |       |        |
| ) |                                                 |       |        |
| * |                                                 |       |        |
+---+-------------------------------------------------+-------+--------+
| 4 | Problems encountered                            |       |        |
+---+-------------------------------------------------+-------+--------+
|   |                                                 |       |        |
+---+-------------------------------------------------+-------+--------+
| 5 | Final cost of project                           |       |        |
+---+-------------------------------------------------+-------+--------+
|   | Contribution by USAID                           | \$    |        |
+---+-------------------------------------------------+-------+--------+
|   | Contribution by U. S. Sponsoring Organization   | \$    |        |
|   | (USO)                                           |       |        |
+---+-------------------------------------------------+-------+--------+
|   | Contribution by the Overseas Sponsored          | \$    |        |
|   | Institution (OSI)                               |       |        |
+---+-------------------------------------------------+-------+--------+
|   | Contribution by Other Non-Federal Sources       | \$    |        |
+---+-------------------------------------------------+-------+--------+
|   | TOTAL                                           | \$    |        |
+---+-------------------------------------------------+-------+--------+
| 6 | **[Statistical Information]{.smallcaps}**       |       |        |
|   | *(enter as appropriate for your organization)*  |       |        |
+---+-------------------------------------------------+-------+--------+
|   | ####  required data                             | **    | **[num |
|   |                                                 | [date | ber]{. |
|   |                                                 | ]{.sm | smallc |
|   |                                                 | allca | aps}** |
|   |                                                 | ps}** |        |
+---+-------------------------------------------------+-------+--------+
|   | 1\. Enrollment *(schools, universities,         |       |        |
|   | training centers)*                              |       |        |
+---+-------------------------------------------------+-------+--------+
|   | *Describe:*                                     |       |        |
+---+-------------------------------------------------+-------+--------+
|   | 2\. Size of last graduating class *(all)*       |       |        |
+---+-------------------------------------------------+-------+--------+
|   | *Describe:*                                     |       |        |
+---+-------------------------------------------------+-------+--------+
|   | 3\. Square footage added *(for construction     |       |        |
|   | projects)*                                      |       |        |
+---+-------------------------------------------------+-------+--------+
|   | *Describe:*                                     |       |        |
+---+-------------------------------------------------+-------+--------+
|   | 4\. Distance learning *(number of               |       |        |
|   | participants)*                                  |       |        |
+---+-------------------------------------------------+-------+--------+
|   | *Describe:*                                     |       |        |
+---+-------------------------------------------------+-------+--------+
|   | 5\. Program added *(curriculum, et al)*         |       |        |
+---+-------------------------------------------------+-------+--------+
|   | *Describe:*                                     |       |        |
+---+-------------------------------------------------+-------+--------+
|   | 6\. Service delivery                            |       |        |
+---+-------------------------------------------------+-------+--------+
|   | *Describe:*                                     |       |        |
+---+-------------------------------------------------+-------+--------+
|   | 7\. Other                                       |       |        |
+---+-------------------------------------------------+-------+--------+
|   | *Describe:*                                     |       |        |
+---+-------------------------------------------------+-------+--------+

# 

# Section 7 - Performance Report 

# 

# 

# 

# USO: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**OSI:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**ASHA Grant No:** ­\_\_\_\_/\_\_\_ **Amount: US\$**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Date Awarded:** \_\_/\_\_/\_\_\_\_

**Period Covered:** \_\_/\_\_/\_\_\_\_ to \_\_/\_\_/\_\_\_\_

**Project Title:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# 

*Develop briefly and concisely the following outline:*

-   Technical and Medical Terms and Acronyms (*definitions*)

```{=html}
<!-- -->
```
-   Project Financed by ASHA (*a brief description*)

-   Delays (or Timeliness) of Grant Activity Implementation

-   Accomplishments to Date

    1.  OSI's Access to U.S. Technologies and Practices (*as
        demonstrated by the number and percent of U.S. citizens and U.S.
        trained persons employed by the OSI and by U.S. standard medical
        diagnostics and laboratory equipment, computers and software,
        information technology accessories acquired by the OSI*)

    2.  Demonstration of U.S. Educational and Medical Technologies and
        Practices (*include number of students successfully enrolled,
        patients diagnosed and treated, and local community
        participation through outreach programs*)

    3.  Quality of the OSI's Program (*illustrated by achievement of its
        graduates, health status of patients and its impact on the
        host-country's educational and/or medical policies and
        practices*)

    4.  Progress Made on End-results (*explain how the PMP was used to
        guide achievement of results*)

    5.  Luminary Alumni (*a mention of them often measures the caliber
        of the OSI's*)

```{=html}
<!-- -->
```
-   Success Stories (*presented in layman's language*)

*(Section 7 -- continued)*

**OSI: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Results Framework**

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 12%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 11%" />
<col style="width: 13%" />
<col style="width: 9%" />
<col style="width: 14%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2" rowspan="2"></td>
<td></td>
<td colspan="3"><p><strong>Strategic Objective 1:</strong></p>
<p>(enter objective statement)</p></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"><p><strong>Intermediate Result 1.1:</strong></p>
<p>(enter IR statement)</p></td>
<td></td>
<td></td>
<td colspan="2"><p><strong>Intermediate Result 1.2:</strong></p>
<p>(enter IR statement)</p></td>
<td></td>
<td colspan="4"><p><strong>Intermediate Result 1.3:</strong></p>
<p>(enter IR statement)</p></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="11"><blockquote>
<p><strong>Activities</strong></p>
</blockquote>
<ul>
<li><p>(enter activity)</p></li>
<li></li>
</ul></td>
</tr>
</tbody>
</table>

*(Section 7 -- continued)*

**TABLE 1: PERFORMANCE INDICATORS BASELINE AND PERFORMANCE TARGETS**

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 24%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 17%" />
</colgroup>
<thead>
<tr class="header">
<th rowspan="3"><strong>STRATEGIC OBJECTIVE, IR RESULT,
INDICATOR</strong></th>
<th rowspan="3"><h1 id="definition">DEFINITION</h1></th>
<th colspan="3"><strong>BASELINE YEAR &amp; VALUE</strong></th>
<th colspan="5"><strong>PROFORMANCE</strong></th>
<th><strong>STATUS OF CRITICAL ASSUMPTIONS</strong></th>
</tr>
<tr class="odd">
<th rowspan="2"><strong>Year</strong></th>
<th colspan="2" rowspan="2"><strong>Value</strong></th>
<th colspan="5"><strong>200x</strong></th>
<th></th>
</tr>
<tr class="header">
<th colspan="2"><strong>Target</strong></th>
<th colspan="2"><strong>Actual</strong></th>
<th><strong>Progress</strong></th>
<th></th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td colspan="11"><p><strong>Strategic Objective 1:</strong> (enter
statement of objective)</p>
<p>.</p></td>
</tr>
<tr class="even">
<td>1. (enter indicator)</td>
<td><p><strong>Definition:</strong></p>
<p><strong><u>Unit:</u></strong></p></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2. (enter indicator)</td>
<td><p><strong>Definition:</strong></p>
<p><strong>Unit:</strong></p></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>Intermediate Result 1.1:</strong> (enter
statement of IR)</td>
</tr>
<tr class="odd">
<td>1. (enter indicator)</td>
<td><p><strong>Definition:</strong></p>
<p><strong>Unit:</strong></p></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>2. (enter indicator)</td>
<td><p><strong>Definition:</strong></p>
<p><strong>Unit:</strong></p></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Intermediate Result 1.2:</strong> (enter IR
statement)</td>
</tr>
<tr class="even">
<td>1. (enter indicator)</td>
<td><p><strong>Definition:</strong></p>
<p><strong>Unit:</strong></p></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>Intermediate Result 1.3:</strong> (enter IR
statement)</td>
</tr>
<tr class="odd">
<td>1. (enter indicator)</td>
<td><p><strong>Definition:</strong></p>
<p><strong>Units:</strong></p></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>2. (enter indicator)</td>
<td><p><strong>Definition:</strong></p>
<p><strong>Unit:</strong></p></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Comments/Notes:</strong></td>
</tr>
</tbody>
</table>

(end of Section 7)

+---+---------------------------------+---------------------------------+
| # |                                 |                                 |
| # |                                 |                                 |
|   |                                 |                                 |
| P |                                 |                                 |
| R |                                 |                                 |
| O |                                 |                                 |
| J |                                 |                                 |
| E |                                 |                                 |
| C |                                 |                                 |
| T |                                 |                                 |
|   |                                 |                                 |
| E |                                 |                                 |
| V |                                 |                                 |
| A |                                 |                                 |
| L |                                 |                                 |
| U |                                 |                                 |
| A |                                 |                                 |
| T |                                 |                                 |
| I |                                 |                                 |
| O |                                 |                                 |
| N |                                 |                                 |
|   |                                 |                                 |
| * |                                 |                                 |
| ( |                                 |                                 |
| c |                                 |                                 |
| o |                                 |                                 |
| n |                                 |                                 |
| t |                                 |                                 |
| i |                                 |                                 |
| n |                                 |                                 |
| u |                                 |                                 |
| e |                                 |                                 |
| d |                                 |                                 |
| ) |                                 |                                 |
| * |                                 |                                 |
+---+---------------------------------+---------------------------------+
| 8 | Benefit provided (*tangible     |                                 |
|   | project outputs)*:              |                                 |
+---+---------------------------------+---------------------------------+
|   | Grantee with Continuing or      |                                 |
|   | Historical Support *(enter as   |                                 |
|   | appropriate for the sponsored   |                                 |
|   | OSI)*                           |                                 |
+---+---------------------------------+---------------------------------+
| 9 | ### **Long term objectives**    | ***Results achieved with ASHA   |
|   |                                 | and other assistance***         |
+---+---------------------------------+---------------------------------+
|   | a)  **[enrollment               |                                 |
|   |     capacity]{.smallcaps}**     |                                 |
|   |     *(enter information on      |                                 |
|   |     planned changes in          |                                 |
|   |     enrollment as a whole or    |                                 |
|   |     for target group)*          |                                 |
+---+---------------------------------+---------------------------------+
|   | b)  [**technical                |                                 |
|   |     capacity**]{.smallcaps}     |                                 |
|   |     *(enter planned changes in  |                                 |
|   |     technical capacity -- labs, |                                 |
|   |     access to changes in        |                                 |
|   |     technology, i.e.,           |                                 |
|   |     communications, Internet,   |                                 |
|   |     et cetera)*                 |                                 |
+---+---------------------------------+---------------------------------+
|   | c)  **[access by vulnerable     |                                 |
|   |     groups]{.smallcaps}**       |                                 |
|   |     *(targets for distance      |                                 |
|   |     learning, scholarship to    |                                 |
|   |     disadvantaged groups)*      |                                 |
+---+---------------------------------+---------------------------------+
| # |                                 |                                 |
| # |                                 |                                 |
|   |                                 |                                 |
| P |                                 |                                 |
| R |                                 |                                 |
| O |                                 |                                 |
| J |                                 |                                 |
| E |                                 |                                 |
| C |                                 |                                 |
| T |                                 |                                 |
|   |                                 |                                 |
| E |                                 |                                 |
| V |                                 |                                 |
| A |                                 |                                 |
| L |                                 |                                 |
| U |                                 |                                 |
| A |                                 |                                 |
| T |                                 |                                 |
| I |                                 |                                 |
| O |                                 |                                 |
| N |                                 |                                 |
|   |                                 |                                 |
| * |                                 |                                 |
| ( |                                 |                                 |
| c |                                 |                                 |
| o |                                 |                                 |
| n |                                 |                                 |
| t |                                 |                                 |
| i |                                 |                                 |
| n |                                 |                                 |
| u |                                 |                                 |
| e |                                 |                                 |
| d |                                 |                                 |
| ) |                                 |                                 |
| * |                                 |                                 |
+---+---------------------------------+---------------------------------+
| 9 | ### **Long term objectives**    | ***Results achieved with ASHA   |
|   |                                 | and other assistance***         |
+---+---------------------------------+---------------------------------+
|   | d)  **[service                  |                                 |
|   |     delivery]{.smallcaps}**     |                                 |
|   |     *(increases in curriculum   |                                 |
|   |     targets and qualifications  |                                 |
|   |     of professional staff)*     |                                 |
|   |                                 |                                 |
|   | ###                             |                                 |
+---+---------------------------------+---------------------------------+
|   | e)  **[quality]{.smallcaps}**   |                                 |
|   |     *(for schools and           |                                 |
|   |     universities, client focus  |                                 |
|   |     and accreditation; for      |                                 |
|   |     hospitals, client focus     |                                 |
|   |     plus pier review, community |                                 |
|   |     outreach, et cetera)*       |                                 |
+---+---------------------------------+---------------------------------+
|   | f)  [**focus of                 |                                 |
|   |     research**]{.smallcaps}     |                                 |
|   |     *(for research centers,     |                                 |
|   |     type of research, such as,  |                                 |
|   |     operational, basic,         |                                 |
|   |     biomedical, et cetera)*     |                                 |
+---+---------------------------------+---------------------------------+
|   | g)  **[other]{.smallcaps}**     |                                 |
+---+---------------------------------+---------------------------------+
|   | h)  **[other]{.smallcaps}**     |                                 |
+---+---------------------------------+---------------------------------+

  ------------ ------------------------------------------- ----------- -----------------
  10           **[ASHA Evaluation]{.smallcaps}** *(for                 
               ASHA only)*                                             

                                                                       

                                                                       

                                                                       

                                                                       

  Grantee's                                                            
  Official:                                                            

  Name of                                                  Position:   
  authorized                                                           
  signatory:                                                           

  Authorized                                                           Date:
  signature                                                            

  PVC-ASHA's                                                           
  Official:                                                            

  Approved by                                                          Date:
  *(PVC-ASHA                                                           
  Grant                                                                
  Officer)*                                                            
  ------------ ------------------------------------------- ----------- -----------------