ACTION FOR WOMEN’S HEALTH

APPLICATION

ACTION FOR WOMEN’S HEALTH APPLICATION

Section A: Registration
❑ Acceptance of Rules. By checking this box, you and the Applicant Organization are accepting the
Rules for this Open Call and consenting to the use of your and the Applicant Organization’s data, as
described in the application and in the Rules. You are also representing that you have the authority to
act on behalf of the Applicant Organization. Please take time to read and understand your rights and
obligations before proceeding. The Rules include all of the Open Call Rules and other stipulations
governing your participation in this Open Call that are described within this website. By registering to
participate in this Open Call, you are providing your consent regarding use of your and the Applicant
Organization’s data through an affirmative act, establishing a freely given, specific, informed, and
unambiguous indication of your agreement for us to process any personal data relating to you or to
the Applicant Organization’s participation in the Open Call and related charitable activities. Should
you have any questions regarding use of your or the Applicant Organization’s data, please email
[email protected] during the course of the Open Call, or, if after the Open
Call, the contact listed in the respective policy for the Open Call Sponsor, Lever for Change or
Submittable. Should you or the Applicant Organization not provide the personal or other data we
request, or should you or the Applicant Organization request to limit the use of such data, we may be
unable to consider the Applicant Organization’s application or award the Application Organization a
grant through this Open Call.

Welcome to the Action for Women’s Health Open Call. By expressing your interest, you agree to receive
periodic news and updates regarding key deadlines, informational webinars, further funding opportunities,
and other program-related messages. Before completing registration, take time to read the following
information:

• Review the Organizational Readiness Tool so that you can better understand if your team will be
competitive in the application process.
• Read the Rules and other related content on this website that stipulate your rights and obligations as a
registrant.
• Review the Application, Timeline, and Scoring Process to understand what and when tasks are required of
registrants.
• Should your organization advance to various stages of the Open Call, your registration will be shared with
other applicants as a part of Participatory Review and, if you advance further, with Evaluation Panel
Reviewers as a part of Evaluation Panel Review.

NOTE: Responses to these questions must be in English.

In order to submit an application to the Action for Women’s Health Open Call, you must complete this
registration form no later than Tuesday, December 3, 2024, at 4:00 p.m. U.S. Central Time. Only registered
organizations may apply.

All fields are required unless otherwise noted.

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A. ADMINISTRATIVE INFORMATION
In this section, please provide information about the Applicant Organization. Before answering, use the
Organizational Readiness Tool to understand your ability to be competitive based on scoring criteria,
eligibility, and capacity. This section will be viewed by peer and Evaluation Panel Reviewers of the Open
Call. Individuals’ email addresses and phone numbers will not be shared with peers or Evaluation Panel
Reviewers of the Open Call. The deadline to complete registration is Tuesday, December 3, 2024, at 4:00
p.m. U.S. Central Time.

Organization Legal Status

What is the legal status of the Applicant Organization?

o An entity based in the United States and/or U.S. Territories that has received a tax determination
letter from the Internal Revenue Service (“IRS”) that it is exempt from federal income tax as an
organization described under section 501(c)(3) of the Internal Revenue Code (“IRC”) and a publicly
supported organization described under section 509(a)(1) or (2) of the IRC, and which tax
determination letter is in effect.
o A nonprofit organization for a fiscally sponsored project, provided that the nonprofit organization is
an entity based in the United States and/or US Territories and has received an IRS determination
letter that it is exempt from federal income tax as an organization described under section 501(c)(3) of
the IRC and a publicly supported organization described under section 509(a)(1) or (2) of the IRC and
which tax determination letter is in effect (or meets the equivalency standards for entities organized
under the laws of a foreign jurisdiction); fiscal sponsors must exercise discretion and control over the
grant funds.
o An entity based in the United States and/or U.S. Territories that has received a tax
determination letter from the IRS that it is exempt from federal income tax as an organization
described under section 501(c)(3) of the IRC and is also classified as a Type I or Type II
supporting organization described under section 509(a)(3) of the IRC, and which tax
determination letter is in effect.
o A U.S. tribal government treated as a State pursuant to IRC Section 7871.
o An entity organized under the laws of a foreign jurisdiction which has received a tax
determination letter from the IRS or has been determined to be the equivalent of a section
501(c)(3) and 509(a)(1) or (2) entity by NGOsource for which an equivalency determination has
not expired and would be in effect or could extend through the date of award payment.
o An entity that is recognized under the law of the applicable jurisdiction as a non-governmental
organization, a higher education organization, a charitable organization, a not-for-profit
organization, or similar-type entity that is not a for-profit organization or government agency
(except for state universities or U.S. tribal governments treated as a State pursuant to IRC
Section 7871) and that is engaged in charitable activities within the meaning of section
501(c)(3) of the IRC.
o Affiliates of national organizations as long as the affiliate is a separate 501(c)(3) and 509(a)(1)
or (2) entity (or foreign equivalent) and has its own board of directors; legal liability rests with
the local organization; affiliate’s tax-exempt status was not granted under a group exemption;
affiliate makes decisions regarding overall mission, priorities, and strategies of organization
and for day-to-day operations; and affiliate does not “fund” general activities of national
organization.

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Institution Affiliation
Is the Applicant Organization a specific lab or center housed within an institution of higher learning (e.g., a
college or university) or a specific department or program housed within a larger organization?
o Yes
o No

[If “A fiscally sponsored nonprofit organization” is selected above] Special Guidance for Fiscal Sponsors
and Fiscally Sponsored Projects
Fiscally sponsored projects with a fiscal sponsor that has a tax determination letter from the Internal Revenue
Service (IRS) of the United States in effect (or meets the above equivalency standards for entities organized
under the laws of a foreign jurisdiction) are welcome to apply to Action for Women’s Health. Per the National
Council of Nonprofits, a fiscal sponsor is a nonprofit organization that provides fiduciary oversight, financial
management, and other administrative services to help build the capacity of a charitable project. For
grantmaking purposes, the fiscal sponsor organization must be the formal applicant and information of the
fiscal sponsor organization should be provided in answer to the following questions:
• Applicant Organization Legal Name
• Applicant Organization Location
• Applicant Organization Address
• Organization Identification Number
• Year of Formation

All other questions in this form, and all questions in the Application, unless otherwise specified, should
be answered as they pertain to the fiscally sponsored project. An organization that is serving as a fiscal
sponsor for multiple fiscally sponsored projects may submit an application on behalf of each eligible,
separate project.

[If Applicant indicates that, “Yes” they are a specific lab or center housed within an institution of higher
learning or a specific department or program housed within a larger organization] Special Guidance for
Labs, Centers, Departments, and Programs
Specific labs and centers housed within an institution of higher learning (e.g., a college or university) are
welcome to apply to Action for Women’s Health, provided that the college or university is an eligible
organization according to the Open Call Rules. Likewise, existing departments or programs whose sole
purpose is improving women’s health may apply even if their parent organizations have a broader purpose.
For grantmaking purposes, the college, university, or organization within which the
lab/center/program/department is housed must be the formal applicant and its information should be
provided in answer to the following questions:
• Applicant Organization Legal Name
• Applicant Organization Location
• Applicant Organization Address
• Organization Identification Number
• Year of Formation

All other questions in this form, and all questions in the Application, unless otherwise specified, should
be answered as they pertain to the specific lab, center, department, or program.

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Applicant Organization Legal Name

Provide the legal name of the Applicant Organization that may assume responsibility for receiving and taking
accountability for any grant funds, as well as providing the direction, control, and supervision for the work. If
you are a fiscally sponsored project, please provide the legal name of the fiscal sponsor organization, not the
name of the project, here.
[TEXT BOX: 15 words]

[If “A nonprofit organization for a fiscally sponsored project” is selected in response] Project Name
Please provide the name of the fiscally sponsored project to which, if selected as an awardee, these funds will
be dedicated.

[If Applicant indicates that, “Yes” they are a specific lab or center housed within an institution of higher
learning or a specific department or program housed within a larger organization] Lab, Center,
Program, or Department Name
Please provide the name of the specific lab, center, program, or department to which, if selected as an
awardee, these funds will be dedicated.

Applicant Organization Location

Is your organization based in the United States or U.S. Territories?
Fiscally sponsored projects: please provide the location of the fiscal sponsor.

o Yes, our organization is based in the United States or U.S. Territories.

o No, our organization is not based in the United States or U.S. Territories.

[FOR APPLICANTS THAT ARE U.S.-BASED] Applicant Organization Address:

In the space above, please provide your organization’s physical mailing address.
Fiscally sponsored projects: please provide the physical mailing address of the fiscal sponsor.

Country [MENU: STANDARDIZED LIST OF OPTIONS]

Does the Applicant Organization exist within a Tribal Territory? [Yes or No]

State [MENU: STANDARDIZED LIST OF OPTIONS]

Street address [TEXT BOX: 10 words maximum]

Address line 2 (optional) [TEXT BOX: 10 words maximum]

City [TEXT BOX: 5 words maximum]

Zip / Postal Code [TEXT BOX: 5 words maximum]

[FOR APPLICANTS THAT ARE NOT U.S.-BASED] Applicant Organization Address:

Please provide your organization’s physical mailing address.

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Country [MENU: STANDARDIZED LIST OF OPTIONS]

Street address [TEXT BOX: 10 words maximum]

Address line 2 (optional) [TEXT BOX: 10 words maximum]

City [TEXT BOX: 5 words maximum]

Zip / Postal Code [TEXT BOX: 5 words maximum]

Organization Identification Number

The Applicant Organization must be incorporated in an appropriate jurisdiction. Typically, an identifying
number is provided upon incorporation or for tax filings. Select the Country and Identification Type of number
that the Applicant Organization has been provided.

o United States: Employer Identification Number (EIN)

o Australia: Australia Business Number (ABN)
o Brazil: CNPJ (for companies)
o Canada: Revenue Agency Business/Registration Number
o India: FCRA Registration Number
o Netherlands: KVK Number
o South Africa: Nonprofit Organization Number
o United Kingdom: Charity Number
o United Kingdom: Company Number
o OTHER. Enter name of country: [TEXT BOX: 5 words]

Year of Formation
Please enter the year (YYYY) in which the organization was formed. Fiscally sponsored projects: please provide
the year of formation for the fiscal sponsor organization.
[DATE ENTRY: 4 characters]

[If Organization Legal Status is an entity organized or recognized under the laws of a foreign jurisdiction
(Option 5 or 6 is selected in response to Organization Legal Status)] Equivalency Determination
Has the Applicant Organization previously been determined to be the equivalent of a 501(c)(3) and 509(a)(1)
or (2) organization by NGOsource for which equivalency determination (ED) has not expired and would be in
effect or could extend through the date of award?

o Yes, the Applicant Organization is certified in the NGOsource repository and has received an ED
Certificate that is valid through December 2025.
o The Applicant Organization has previously received an ED Certificate from NGOsource, however it has
since expired or will be expired by December 2025.
o No, the Applicant Organization has not been certified as the equivalent of a 501(c)(3) and 509(a)(1) or
(2) and will require an equivalency determination.

Applicant Organization Website or Social Media Page

What is the URL of the website or social media page of choice for the Applicant Organization? If the Applicant
Organization does not have a website or social media page, insert “Not Applicable.”

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[TEXT BOX: 5 words]

Note on Application Contacts

All correspondence related to the Open Call, including deadline reminders and status updates, will be sent
through the Submittable platform by the Action for Women’s Health Team. This correspondence will be directed
to the Submitter whose account is associated with the application. For this reason, it is recommended that the
desired Primary Contact create a Submittable account and complete the application from this account. This will
ensure that they receive all relevant correspondence and updates. Fiscally sponsored projects: please ensure
that you provide contact information for at least one contact at the fiscal sponsor organization.

Primary contact name

Enter the name of the Applicant Organization’s primary point of contact who will answer any questions and
has a working knowledge of the information provided in this form. In the event that your organization is
selected for an award, this person will be contacted to coordinate disbursement details.

First Name [TEXT BOX: 5 words]

Last Name [TEXT BOX: 5 words]

Primary contact title [TEXT BOX: 10 words]

Primary contact phone [TEXT BOX: 5 words]

Primary contact email [TEXT BOX: 5 words]

Secondary contact name

Provide the name of a secondary contact. This person should also be someone who can answer any questions
and has a working knowledge of the information provided in this form.

First Name [TEXT BOX: 5 words]

Last Name [TEXT BOX: 5 words]

Secondary contact title [TEXT BOX: 10 words]

Secondary contact phone [TEXT BOX: 5 words]

Secondary contact email [TEXT BOX: 5 words]

B. LEVER FOR CHANGE STANDARD QUESTIONS

Questions in this section are standard across all Lever for Change initiatives. These questions help Lever for
Change learn more about prospective applicants and will inform outreach efforts in future initiatives. This
section will not be viewed by peer or Evaluation Panel Reviewers of the Open Call.

How did you hear about Action for Women’s Health? You may select more than one.

❑ Email or other direct outreach from Lever for Change

❑ Email or other direct outreach from Pivotal

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❑ Email or other direct outreach from other source. Please describe: [TEXT BOX: 10 words]
❑ Informed by a friend or colleague
❑ Article, blog post, or other news source. Please describe: [TEXT BOX: 10 words]
❑ Social media (e.g., Facebook, Twitter, LinkedIn). Please describe: [TEXT BOX: 10 words]
❑ Partner organization. Please describe: [TEXT BOX: 10 words]
❑ Event. Please describe: [TEXT BOX: 10 words]
❑ Other. Please describe: [TEXT BOX: 10 words]

Consent for Future Communications

I consent to receiving email communications from Lever for Change, including updates on future challenges,
news, and opportunities.
❑ Yes
❑ No
--------------------------------------------------------------------------------------
Section B: Application
The following sections have been strategically sequenced to create a narrative flow for the reviewers.
Thank you for participating in Action for Women’s Health.

Lever for Change recommends reading all requirements for this application before you begin. We encourage
you to review the Scoring Rubric that will be used to assess all valid applications. Applications must be
submitted in English. We understand that using English as the sole language for our review process may pose
a challenge to those who do not speak it as their first language. However, we made this decision to ensure
consistency and minimize the risk of translation errors or misinterpretations in the a pplication process.
Please note that English language proficiency is not a requirement for applying. Thank you for your
accommodation and understanding. We encourage everyone to apply regardless of their language
background.

Kindly take note that if your project progresses through different stages of the challenge, it will be evaluated
by no less than four Participatory Reviewers, four Evaluation Panel reviewers, as well as Action for Women’s
Health stakeholders, and administrators. Your application may be shared online and with other evaluators. To
get a better idea of what information may be displayed, you can visit the Bold Solutions Network and view
previous initiatives.

You must submit your application no later than Friday, January 10, 2025, at 4:00 p.m. U.S. Central Time.

A. ADMINISTRATIVE INFORMATION
In this section, please provide administrative information about the Applicant Organization. Before
answering, use the Organizational Readiness Tool to understand your ability to be competitive according to
the size of your annual operating budget. This section will not be viewed by peer and Evaluation Panel
Reviewers of the Open Call.

Annual Operating Budget

What is the annual operating budget in United States Dollars (USD) of the Applicant Organization? The
following categories are standard across Lever for Change initiatives.

o Less than $1 Million

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o $1.0 to 5.0 Million

o $5.1 to 10 Million
o $10.1 to 25 Million
o $25.1 to 50 Million
o $50.1 to 100 Million
o $100.1 to 250 Million
o $250.1 to 500 Million
o $500.1 to 750 Million
o $750.1 Million to $1 Billion
o $1 Billion +
[RADIO BUTTONS]

Number of Employees
How many full-time employees does the Applicant Organization employ? The following categories are
standard across Lever for Change initiatives.

o Fewer than 10 Full-time Employees

o 10 to 25 Full-time Employees
o 26 to 50 Full-time Employees
o 51 to 100 Full-time Employees
o 101 to 300 Full-time Employees
o 301 to 500 Full-time Employees
o 501 to 1,000 Full-time Employees
o 1,000+ Full-time Employees
[RADIO BUTTONS]

B. SUBJECT AREA, PRIORITY POPULATIONS, AND LOCATION OF WORK

Should your organization advance to further phases of the Open Call, you may be eligible for inclusion in
Lever for Change’s Bold Solutions Network. Lever for Change will use primary subject area, locations of
current work, populations served, and key words to tag your organization in the Bold Solutions Network,
making it possible for other funders to identify organizations they might find interesting to support. This
section will be viewed by peer and Evaluation Panel Reviewers of the Open Call.

Primary Subject Area

Select the primary subject area of your organization’s work. The following subject area categories are
standard across Lever for Change initiatives.

Secondary Subject Area

Optional. Select a secondary subject area of your organization’s work. The following subject area categories
are standard across Lever for Change initiatives.

Key Words and Phrases

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Provide a list of up to 5 key words or phrases that can best be used to describe your organization’s work [ex.
Social-enterprise, vocation, internship, training]. Choose key words that capture the essence of your
organization and its mission. The key words should be different from the selected “primary subject area.”
[TEXT BOX: 5 words]

Location of Current Work

In which community (or communities) does your organization currently work? Select up to five locations that
apply. If your work is global, national, or regional, please select locations that best represent the work your
organization does.

Location of Current Work 1 Country: [COUNTRY DROPDOWN MENU]

[IF UNITED STATES IS SELECTED] Location of Current Work 1 State: [STATE DROPDOWN MENU]

[Applicants to provide above information for up to five current locations of work]

Populations Served
The purpose of this question is to understand the profile of the populations your organization serves. Select
the population(s) that are the primary beneficiaries of your organization’s work. You must select at least one
population, and you are welcome to provide up to three.

POPULATION #1: SELECT FROM LIST OF OPTIONS

POPULATION #2: SELECT FROM LIST OF OPTIONS

POPULATION #3: SELECT FROM LIST OF OPTIONS

C. QUICK PITCH
Make a powerful first impression by providing a concise and captivating summary of your organization’s work.
Please avoid using technical terms, acronyms, or complex language that may be difficult for the general
public to comprehend. The information in this section is likely to be made publicly available in a variety
of online settings and will be viewed by peer and Evaluation Panel Reviewers of the Open Call.

Description of Work (35 words)

Provide a short description of your organization’s work in one sentence using language that can be
easily understood by non-experts and avoiding jargon and acronyms.

For example: “WMP will scale our innovative and cost-effective Wolbachia method globally to prevent
transmission of mosquito-borne diseases like dengue, Zika, chikungunya and yellow fever.”

[TEXT BOX: 35 words]

Executive Summary (250 words)

Write an overview of your organization’s work that answers the following questions:
• How has your organization meaningfully contributed to improving women’s mental and/or physical
health? You may be focused on improving women’s daily health, their longevity, their access to care,

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their ability to engage in daily life at work and at home, and/or their opportunity to form and support
a family.
• Describe your community and your organization’s relationship to it.
• What is your vision for the future? Describe your plan for continued impact.

Your Executive Summary should be a stand-alone statement of your organization’s work – it will be used to
introduce readers (including peer and Evaluation Panel Reviewers, potential donors, and the public) to your
work. It should not require any other context to clearly explain your work, your success, and your vision for
the future. Please use language that can be easily understood by non-experts and avoid jargon, acronyms,
and use of the first-person where possible.
[TEXT BOX: 250 words]

Affirmation of Approach (250 words)

What gives you confidence that your approach works? Present information and examples that demonstrate
your organization’s track record of impact. These can include formal or informal studies, observations, and/or
other indicators of change as defined by your community. If necessary, you may reference external sources.
Use brackets and numbers to indicate relevant references [#], which you can cite in full below.
[TEXT BOX: 250 words]

External References (150 words)

If you included external references [#s] in the Affirmation of Approach section of your application, provide
more detail here. If not applicable, please insert “Not Applicable.”
[TEXT BOX: 150 words]

D. VIDEO PRESENTATION
You are required to submit a video that captures your organization’s work and contribution to the
improvement of women’s mental and/or physical health. The video is an opportunity to showcase your
passion and to pitch your story in a succinct format. We want you to share your vision with the evaluators in a
way that is different from the written proposal format. This does not need to be a professionally produced
video; a video shot on a smartphone is acceptable.

In order to complete this part of your application, your team will upload a short digital film using YouTube.
Set the Privacy Settings on your video to Public or Unlisted – do not set them to Private. This will be viewed
by peer and Evaluation Panel Reviewers of the Open Call.

Your video may be extracted from your submission and made available to the public and other donors. Appeal
to a broad audience. Video submissions should follow these guidelines or else it will render the registration
ineligible:
• A length of no more than 90 seconds.
• Your video must be in English or subtitled in English, if in another language.
• Your video must be captioned. See instructions on how to caption YouTube videos here.
• Your video should not contain any images of individuals who have not given their permission to be
part of the submission and should not contain images of children (under age 18) without express
written parental consent.
• Your video should not include any copyrighted material (including, but not limited to, music) for
which you do not have a license.

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• Please review YouTube’s Terms of Service located here and any other applicable terms on YouTube’s
website before making and submitting your video.

Here are general suggestions for delivering a high-quality video pitch:

• Introduce yourself and your organization.
• Describe the impact your organization has had on the mental and/or physical health of women in your
community.
• Explain your organization’s approach to addressing the obstacle(s) to improved health faced by
women in your community and describe your success in doing so.
• Explain what is unique about your approach and how it fits into the ecosystem working on the same
issues.

Examples of videos from past Open Calls can be found here. Additional technical guidance on creating and
captioning videos can be found on our Video Supports page.

Paste the full YouTube URL in the box below.

[YOUTUBE URL BOX]

E. YOUR TEAM
Previously, you provided a brief overview of your organization. Now we kindly ask you to focus on the
experience and management of your team. This section will be viewed by peer and Evaluation Panel
Reviewers of the Open Call.

Why Your Team (250 words)

Describe your organization’s leadership and staff. Explain the key role that your people have played in your
organization’s success. Emphasize the skills, capacity, knowledge, lived experience, and/or partnerships your
team possess that have made your organization, and your relationship with the community, successful,
adaptable, and ready to expand its work.
[TEXT BOX: 250 words]

Biographies of Key Staff

For each of the top three staff members responsible for the success of your organization, please provide a
name (First/Last), the staff member’s title, and a brief biographical statement of up to 100 words. The
biographical statement should include a description of the staff member’s responsibilities and emphasize
those credentials and experiences which are most relevant to their work at your organization.

Key Staff #1:

FIRST NAME: 5 word limit

LAST NAME: 5 word limit

TITLE: 10 word limit

BIOGRAPHY: 100 word limit

KEY STAFF #2:

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FIRST NAME: 5 word limit

LAST NAME: 5 word limit

TITLE: 10 word limit

BIOGRAPHY: 100 word limit

KEY STAFF #3
FIRST NAME: 5 word limit

LAST NAME: 5 word limit

TITLE: 10 word limit

BIOGRAPHY: 100 word limit

F. YOUR WORK
This section provides the opportunity for you to more fully explain your organization’s work and approach.
This section will be viewed by peer and Evaluation Panel Reviewers of the Open Call.

Overview of Work (250 words)

Describe the challenge(s) that your organization seeks to address, and how, in the face of the challenge(s),
your organization has contributed to the improvement of women’s mental and/or physical health.
• What challenge(s) do women in your community face when it comes to their mental and/or physical
health? The community you serve may be defined by geography, shared identity, and/or shared
needs.
• How has your organization’s work enabled women in your community to make significant progress to
overcome the challenge(s) and experience improvement in their mental and/or physical health? How
has the overall impact of your organization’s various efforts contributed to this progress? Please
provide examples.
[TEXT BOX: 250 WORDS]

Issue Landscape (250 words)

How does your organization’s work fit into the broader ecosystem of efforts to improve women’s
mental and/or physical health and add value to other organizations working on your issue or in your
community or field? Describe the role that your organization plays in this larger landscape.
[TEXT BOX: 250 WORDS]

Stakeholder Engagement (200 words)

To be effective and sustainable, organizations need support to authentically represent, engage, and increase
the participation of people, communities, sectors, and demographic groups in which it will work, which could
include funders, local leaders, decision-makers, educators, residents, and others.

To what extent are community members represented and engaged in your work, formally and/or informally?
Please describe. [TEXT BOX: 200 WORDS]

Diversity, Equity, and Inclusion (300 words)

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• Explain how your organization authentically embraces diversity, equity, and inclusion across all
aspects, including persons with disabilities, religious or ethnic minorities, people of color,
native/Indigenous peoples, and sexual orientation.
• How does your organization increase access, power, or knowledge for a community, issue, or group
that is under-resourced?
• To what extent is your organization’s commitment to diversity, equity, and inclusion reflected in your
programmatic work? Provide additional details on how you provide opportunities and reasonable
accommodations for those populations to either engage with and/or benefit from your work,
including as staff, advisors, partners, et al.
[TEXT BOX: 250 words]

G. PROJECTED IMPACT OF WORK & RESOURCES

This section provides the opportunity for you to discuss your organization’s approach to measurement and
aspirations for the next few years. This section will be viewed by peer and Evaluation Panel Reviewers of
the Open Call.

Assessment of Results (250 words)

How does your organization assess the effectiveness of its efforts? Provide a few examples.
[TEXT BOX: 250 words]

Why Now? (250 words)

What do you hope to achieve over the next three years? How would a $1 million grant strengthen your
organization, your work, and your community?

Please note: Each awardee will receive a grant of at least $1 million USD. The grants made as a result of the
Action for Women’s Health open call will total to $250 million USD. For more information on number and size of
grants, please refer to the FAQs.
[TEXT BOX: 250 words]

Vision for Growth (250 words)

Should you receive a $1 million award, how would you scale or expand your organization’s work and impact?
What information, experience, or evidence leads you to believe your results can be replicated? How will you
ensure that this growth is sustainable? As you prepare your response, read Scaling-Up: Tools & Techniques for
Practitioners.
[TEXT BOX: 250 WORDS]

Other Considerations (150 words)

This is your final opportunity to raise any other considerations. Here, you may emphasize or expand upon a
previous point or provide new information, as necessary.
[TEXT BOX: 150 words]

H. ADDITIONAL DUE DILIGENCE

The following information is required for due diligence purposes. This section will not be shared with peer
or Evaluation Panel Reviewers of the Open Call. Should you advance to further phases of the Open Call,

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the information provided in this section will be reviewed by Lever for Change as part of due diligence
considerations.

Governance Structure
Please provide any documents illustrating the governance structure of the Applicant Organization (e.g., Trust
Deed, Constitution, Memorandum and Articles of Association, Bylaws, Statutes, Charter, etc.). You must
upload a single PDF no larger than 10MB in size.

Proof of Registration
Please provide proof of the Applicant Organization’s formation and registration under the law of the
applicable jurisdiction and its tax-exempt status (e.g., Tax Determination Letter, Certificate of Incorporation,
Articles of Incorporation, Trust Deed, Certificate of Registration, etc.).
Fiscally sponsored projects: please provide proof of registration for the fiscal sponsor organization.

[FOR APPLICANTS THAT ARE U.S.-BASED] Audited Financial Statements

The two (2) (and up to three (3)) most recent consecutive fiscal years of data from your organization’s Audited
Financial Statements are required. These Audited Financial Statements should include: (1) the Independent
Auditors Report; (2) the Statement of Financial Position; (3) the Statement of Activities; (4) the Statement of
Cash Flows; and (5) the Notes to the Financial Statements (if any) under U.S. GAAP.

If your organization is not required by state law to conduct an independent audit, please instead provide at
least two years of financial documents that, at a minimum, show the organization’s income, expenditure, and
assets/liabilities.

You must upload a single PDF file that does not exceed 10MB.

[FOR APPLICANTS THAT ARE U.S.-BASED] Form 990

Please attach the Applicant Organization’s most recent Form 990 as a PDF.
Fiscally sponsored projects: please provide the fiscal sponsor organization’s most recent Form 990.

[FOR APPLICANTS THAT ARE NOT U.S.-BASED] Audited Financial Statements

We require information necessary to understand the financial health of the Applicant Organization. Upload
audited financial reports from the past two (2) (and up to three (3)) years for the Applicant Organization.

You may submit the two years of audited financial records in any standard format. You must upload a single
PDF file that does not exceed 10MB. NOTE: Audited financials can be submitted in a different language, if
necessary.

[FOR APPLICANTS THAT ARE NOT U.S.-BASED] Language – Audited Financial Records
If submitting audited financial records in a language other than English, indicate the language(s) below or
please enter “Not Applicable.”
[TEXT BOX: 5 words]

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APPLICATION

[FOR APPLICANTS THAT include a fiscally sponsored project]

Fiscal Sponsorship Agreement (in English)
Please provide proof of the relationship between the fiscal sponsor and fiscally sponsored project in
the form of a fiscal sponsorship agreement. NOTE: For grantmaking purposes, Fiscal Sponsorship
Agreements must be submitted in English.

[FOR APPLICANTS THAT include a fiscally sponsored project]

Audited Financial Statements of Fiscal Sponsor
For U.S.-based Fiscal Sponsors: The two (2) (and up to three (3) most recent consecutive fiscal years of data
from the fiscal sponsor organization’s Audited Financial Statements are also required. These Audited
Financial Statements should include: (1) the Independent Auditors Report; (2) the Statement of Financial
Position; (3) the Statement of Activities; (4) the Statement of Cash Flows; and (5) the Notes to the Financial
Statements (if any) under U.S. GAAP. You must upload a single PDF file for each fiscal year.

If a fiscal sponsor is not required by state law to conduct an independent audit, please instead provide at least
two years of financial documents that, at a minimum, show the organization’s income, expenditure, and
assets/liabilities.

For Internationally based Fiscal Sponsors: The two (2) (and up to three (3)) most recent audited financial
reports from the fiscal sponsor organization are also required. NOTE: Audited financials can be submitted in a
different language, if necessary.

You must upload a single PDF file that does not exceed 10MB.

Age of Organization
Is your organization less than five years old (as of January 1, 2025)? Fiscally sponsored projects: please answer
for the fiscal sponsor.
❑ Yes
❑ No
Current/Previous Funders
Please provide the following information for at least three and up to five of the top funders of your
organization over the last three (3) years. For each funder, provide the legal name of the entity responsible for
funding your organization. Provide the period of funding (in months to date) for the funding. Last, provide the
amount of funding within the prescribed period.

FUNDER #1 NAME: 10 word limit

FIRST YEAR OF FUNDING: mm-yyyy

LAST YEAR OF FUNDING: mm-yyyy

AMOUNT OF FUNDING: Numbers only up to 20 characters

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APPLICATION

Organizational Circumstance
Are any of the following true of the Applicant Organization, either currently or in the last three (3)
years?
Please Note: While none of the following circumstances are likely to be disqualifying, further review may
be undertaken should your organization advance to future phases of this Open Call.

☐ Applicant Organization has an interim leadership team in place or is undergoing a leadership

transition.
☐ Applicant Organization is a defendant in a lawsuit, either pending or in process, where charges may
include claims of discrimination, sexual misconduct, or fraud.
☐ Substantial negative information about Applicant Organization has appeared repeatedly in
print, broadcast, and/or on social media.
☐ None of the above.
[CHECKBOXES: SELECT ALL THAT APPLY]

[IF ONE OF THE ABOVE BOXES BESIDES “NONE OF THE ABOVE” ARE CHECKED:]
Organizational Circumstance Detail
Please feel free to use the text box above to provide any additional information regarding your
response to the Organizational Circumstance question.

I. ADDITIONAL INFORMATION TO BE PROVIDED

If your team is invited to participate in any future phases of this Open Call, you may be required to provide
additional information (refer to the Rules and Timeline), including but not limited to:

• Additional information about your organization, including the organizational circumstances described
in the above question.
• Existing policies, if any, addressing conflicts of interest, whistleblower, internal controls, anti-money
laundering, intellectual property, human subjects research, code of conduct, ethics, gifts, and any
similar policies governing the organization.
• Documentation required to establish Equivalency Determination or Expenditure Responsibility, as
relevant.

Further, please note that the awards in this Open Call may be made in partnership with a donor advised fund
(DAF). Accordingly, any country with a Corruption Perceptions Index (CPI) score of 30 or below in either of the
past two years may require heightened due diligence and may need to be made using expenditure
responsibility procedures. The CPI scores are publicly available on transparency.org (2021 Corruption
Perceptions Index - Explore the… - Transparency.org).

The outcome of this due diligence may be a determination that the funder s unable to make a grant to an
organization located in, conducting activities within, or formed under the laws of the country in question.

As a reminder, organizations working in or with governments of countries on the Office of Foreign Asset
Control (OFAC)’s sanctions list (which currently include Myanmar, Iraq, Sudan, Venezuela, Yemen, Cuba, Iran,
North Korea, Russia, Syria, Afghanistan, Balkans, Belarus, Central African Republic, DRC, Ethiopia, Hong Kong,
Lebanon, Libya, Mali, Nicaragua, Somalia, and South Sudan) or with persons included on OFAC’s SDN list are
not eligible for this open call.

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