Anglophone Regional workshop on Surveillance, Monitoring and Evaluation (SM&E) of Malaria Control Programs

Anglophone Regional workshop on Surveillance, Monitoring and Evaluation (SM&E) of Malaria Control Programs
Anglophone Regional workshop on Surveillance, Monitoring and Evaluation (SM&E) of Malaria Control Programs
Title
Mr.Mrs.Ms.Dr.Other
2. Name
First NameLast Name
3. Other names:
4. Gender
MaleFemale
5. Current position/job title
6. Institutional affiliation
7. Institutional mailing address
example@example.com
8. Business phone number:
Please enter a valid phone number.
9. Mobile phone number:
Please enter a valid phone number.
10. Personal Email:
example@example.com
11. Nearest airport
12. Country of citizenship
13. City & country of birth
14. Date of Birth
MonthDayYear
Date
15. Country of passport (if different than country of citizenship):
16. Passport number
17. Select course option (Only participants who have previously completed an M&E course may apply for option 2)
Option 1.1 - M&E Fundamentals + Malaria surveillance trackOption 1.2 - M&E Fundamentals + Evaluation Methods for malaria trackOption 2.1 - Malaria surveillance track onlyOption 2.2 - Evaluation Methods for malaria track only
18. If you chose an option 2 track, please list the name of the monitoring & evaluation course completed, the date of completion, and the content learned:
19. Post-Secondary Education (Begin with most recent and include in the following order: Dates, Institution attended, Major subject and Degree completed) for example: 1999-2003, University of Ghana, Biology, MSc Biology, etc.)
a) .................................................................................................................

b) ................................................................................................................

c) .................................................................................................................

d) ................................................................................................................
20. Describe your present duties and responsibilities briefly, including both teaching and research, with specific emphasis on work-related monitoring and evaluation activities:
21. List all program monitoring and evaluation experience (Please provide the date, the name of the program, the funding source, your role in monitoring evaluation effort and the location for example: 1999-2000, NMCP, Ministry of Health, M&E Officer, Accra, etc.)
i) .................................................................................................................

ii) ................................................................................................................

iii) ................................................................................................................

iv) ................................................................................................................
22. Does the organization where you currently work receive any funding from USAID for the project that you work on?
23. Which level are you primarily involved with in terms of monitoring and evaluation? (Check one)
National levelProvincial/regional levelDistrict levelSub-district levelOther (e.g. Project level)
24. In which type of organization do you currently work?
Donor organizationNon-governmental organizationGovernmental organizationOther (i.e. Private consultancy, Research organization):....................................................
Should be Empty: