ATTACHMENT_J.5_VERF_TEMPLATE.pdf

Section A: General Information

A.1 Program Theme:

Sending Country: Belarus

Country City/Region:

A.2 USAID Contact

USAID Officer

Position

Office

Telephone Number

Fax Number

E-mail Address

A.3 US Embassy Contact

Contact Name

Telephone Number

Fax Number

E-mail Address

A.4 WL Partner Organization Contact

Name

Organization

Address

Telephone Number

Fax Number

E-mail Address

A.5 Suggested Program Start Date (preferred month/year):

A.6 Number of Visitors: 10

COMMUNITY CONNECTIONS EXCHANGE VISITOR REQUEST FORM

Section B: Intended Group Results

B.1 Background Information

• Provide background information regarding the in-country/regional situation as it relates to the theme. Where/what is the performance gap, why is the program needed and what is going to be accomplished?

• Provide background on the geographic community (town, oblast, metropolitan area, and region) from which candidates will be recruited.

• Provide background on the professional community from which candidates will be recruited.

B.2 Overall Professional Program Goals and Objectives

What are the professional goals of the program? (Should be action-oriented, few, targeted and specific)

What are the objectives of the program under the stated goals? (Each goal should have its own objective and they should be specific, targeted, realistic, and prioritized)

How will this program inspire participants to implement changes in their home country and help to build public-private partnerships?

B.3 Program Components

Suggested site-visits (list specific site-visits/organizations in bullet points)

Suggested topics (list topics visitors will be interested in discussing)

B.4 Overall Cultural Program Goals and Objectives

Are there any specific cultural objectives for this program? (Specific requirements, volunteer activities, etc.)

How will exposure to US culture benefit this group/theme?

Section C: Visitor Profile

C.1 Candidate Recruitment and Selection

How will candidate(s) be identified?

C.2 Summary of Desired Group Profile

C.3 Interpreter requested? Yes Language(s) required:

The interpretation from Russian is required

Section D: Cost Estimates

D.1 Estimated Total U.S. $ Cost per Visitor Type Amount Description

Instructional Cost $

Trainee Cost $

Travel Cost $

Total Est. Cost $ D.2 Other Resources Type Amount Description

Employer $ 0

Host Gov't $ 0

Private $ 0

Host Organization $ 0

Other $ 0

TOTAL $ 0

Section E: Approvals

E.1 Approved by: Position: Date: