POLESTAR AWARD FOR SOCIAL IMPACT - SUBMISSION FORM

1 UNIQUE ID (For Polestar office use only)

2 STATE (from which applied)

3 DISTRICT (from which applied)

4 DATE OF YOUR ONLINE SUBMISSION

A RESPONDENT PROFILE

1 Name of Organization

2 Type of organization – NGO or Corporate

3 Name and designation of Primary Contact Person

4 Does your organization have a Registration Certificate?*

5 Contact details – Email, Mobile and website link

6 Organization PAN CARD No.

7 Category Applied for: (Please tick) • Education• Health• Livelihood• Empowerment

8 Name the key activities you perform within the category

9 Name the State/UT, District/s where you operate

10 When did you start operations?

11 How long have you been operating continuously?

12 Any awards/recognitions/honour conferred?*

B ABOUT YOUR ORGANIZATION

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Vision, Mission and Goals

1 What are the Vision, Mission and Goals of your Organization?

Not more than 150 words

2 What made you to choose the key activities that you perform?

Not more than 150 words

3 Why did you choose the locations where you currently operate?

Not more than 150 words

4 Has your organization focus seen a positive shift over the years? What has been the difference in impact because of this?

Not more than 150 words

Senior Management Leadership (Please highlight your answer choice in red)

1 How many years of experience do the head of this organization have?

▪>10 years ▪6-10 years ▪3-5 years

2 How many formal meetings have the top leadership conducted in the past 1 year?

▪More than 6 meetings▪1-6 meetings ▪No meeting

3 How do you recruit, manage, motivate and ensure quality as well as diversity in your team? Not more than 150 words

4 Do you have a second line of leadership? And does your staff have clearly defined roles and responsibilities Not more than 100 words

5 What strategic partnerships have you built over the past 3 years?Not more than 100 words

Governance (Please highlight your answer choice in red)

1 Does your organization comply with all Statutory Regulations? (80G, 12A, ITR if any )*

▪Yes ▪No

2 Have you filed IT Returns for the years you have been in operation? Please provide supporting documents for the past 2 years.*

▪Yes ▪No

Accounting, audit and reporting (Please highlight your answer choice in red)

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1 Do you update your accounts on a regular (monthly) basis? If yes, how do you maintain your Book of Accounts?

• Yes• No

• Computerized•Manual

2 Do you have a copy of the organization's budget (2016-17)?* ▪Yes ▪ No

3 What is your annual budget allocated for your key activities in INR?*

4 What is your gross expenditure for the last 3 years on key activities?*

5 What are your sources of funding?

6 What financial monitoring systems are in place to monitor your cash flows, budgets and operational expenses? Please describe.

Not more than 100 words

C PROGRAMME MANAGEMENT AND DELIVERY

Programme Management (Please highlight your answer choice in red)

1 Who are your beneficiaries and have you clearly identified their needs?

Not more than 150 words

2 Do you have a formal listing of the services provided to your beneficiaries?

· Yes· No

3 Do you have Programme Planning documents for the last 6 months? For example, do you have Project Implementation Plans (PIP), Logframe Analysis ( LFA) documents?*

▪ Available for all 6 months

▪Available for < 6 months

▪Not available

4 What is the type of Monitoring & Evaluation (M&E) systems followed in your organization?*

▪ Computerized MIS ▪Manually recorded

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M&E forms for all separate projects

▪ No M&E system in

place

5 How many full-time staff does your organization have?

6 How many part-time staff does your organization depute?

7 How many target respondents are addressed by your interventions?

8 How do you disseminate information to your beneficiaries/potential beneficiaries? Please describe

Not more than 100 words

9 What is the communication and reporting pattern – internal to your organization as well as to your external stakeholders? How do you record lessons learnt and feedback into your ongoing project?

Not more than 150 words

10 Please explain how you deliver services to the last mile and how do you control cost and quality?

Not more than 150 words

11 What was the quantitative impact of your activity over a specified period of time? For e.g., how did your activity increase family income, literacy levels, and health improvement levels? *

Not more than 150 words

12 What was the qualitative impact of your activity over a specified period of time? For e.g., how did your activity increase attendance rates at school, improve quality of life, and decrease in alcoholism/substance abuse? *

Not more than 150 words

13 How has the local community been involved? Did it involve a diverse cross section of the community? *

Not more than 150 words

14 Has your project/ programme demonstrated that it is commercially viable and sustainable in the long term? If yes, please explain how

Not more than 150 words

15 Is your operation streamlined to be replicated with ability to scale as required? Please explain how

Not more than 150 words

16 Is there an element of innovation in your project planning, implementation, delivery or outcome? If yes, please describe the

▪Yes ▪No

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same ( in not more than 150 words)

17 What are the barriers/ constraints faced by the project/ programme? How will you overcome them?

Not more than 150 words

18 Do you have a training/capacity building plan? If yes, please describe the same

Not more than 150 words

19 What are your plans for the future? Not more than 150 words

* Please provide supporting documents.

About the Awards:

The POLESTAR FOUNDATION introduced a new category of awards in the year 2017 for Social Impact to

recognise excellence in social development initiatives. Four awards will be given, one each in the

following categories: Education, Livelihood, Health and Empowerment.

The spirit of the award:

Please Note:

· Submissions for Best Social Impact awards are invited for 4 different categories - Education,

Livelihood, Health and Empowerment

· Please provide Supporting documents - Copy of 12A / 80G certificate (For NGO only), Copy of

certificate from auditor for your expense on CSR (For Corporate only), Copy of income-expenditure

account and balance sheet (For NGO only), and other supporting documents (For NGO / Corporate).

All the supporting documents will have to be shared via email or WeTransfer.

· The applicants MUST state the reasons why he/she believes the social work deserves an award.

· All submissions should be sent via E-MAIL ONLY to polestarsocialimpact@gmail.com.

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CelebrateThe Award is to celebrate holistic human development through projects that are sustainable and capable of scaling quickly to impact a larger population.

ConnectWe aim to use this initiative to connect with committed social impact organizations that are transforming lives across the country through their programs.

CatalyzeThrough the Polestar Award we hope to inspire and accelerate outstanding initiatives to go further and do more in their fields of expertise.

· The description submitted MUST be sent in a MS Word and PDF format. Videos should be in MP4

format and can be shared via WeTransfer or Google Drive.

· Please send SEPARATE submission forms for each category you are applying for.

· Submissions are invited starting 4th May 2018.

· All submissions should reach The PoleStar Foundation latest by 23th July 2018.

· Please note – there is NO ENTRY FEE for submissions

For further details:

Write to us @ polestarsocialimpact@gmail.com OR info@missionsamriddhi.org OR reach out to our PoleStar guide Mr. Leo James at +91 8754469056.

Visit us @ www.polestar-foundation.org

FAQs

1. How do I fill the entry form?

Applications can be submitted only through the online application form. Start from Part 1 and fill up each part, following the examples and instructions. It may be advisable to download the nomination document, take a print out, fill it up in consultation with your colleagues and use that to finally make the submission online. This will be especially needed if your Internet connection is unsteady.

2. Can I send multiple entries?

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You can send in multiple entries only if you are applying for an award in multiple sectors or for more than one primary activity. For example: if your NGO works in health and education, you can apply for an award in both sectors – but you will have to fill up two separate entry forms.

3. Who can apply for the awards?

Two types of applications are acceptable:

1. Non-Governmental Organizations (NGOs): Trusts or Societies registered under the relevant act in India and currently functioning in India. NGOs set up and primarily funded by corporate bodies are not covered in this category.

2. Corporate Bodies: Any corporate CSR program or a corporate body or an entity set up by it as a society/trust, currently functioning in India.

4. What categories of work are eligible for awards?

Current ongoing initiatives will be considered for the award. Awards will be given for the 4 categories mentioned below. As examples, some types of activities are listed in each category.

1. Education: Examples: education of underprivileged, or challenged children; improving access or quality of education; teacher training; development of teaching aides; development and spread of curriculum; vocational or technical education centers; education in special fields like sports or music, etc.

2. Health: Examples: provision of low cost healthcare; provision or facilitation of basic healthcare to underprivileged sections; encouraging hygiene and other healthy practices; creating infrastructure for these; etc.

3. Livelihoods: Examples: any self- sustaining economic activity leading to income augmentation and employment creation, especially for under privileged sections including women, dalits, tribals; skills development; training in technologies

4. Empowerment: Examples: creating awareness and empowering communities on the above areas as well as areas such as Gram Panchayat governance and administration, Community Forest Rights entitlement, Government welfare schemes such as MGNREGA, health, hygiene and sanitation, women’s rights, RTI, legal rights, social evils like dowry; communal harmony and national integration.

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In case your work spans two or more issues, choose the category that represents maximum social impact. Alternatively apply for more than one category, but remember you will have to submit separate application forms for each category.

5. Will the selection process be transparent and unbiased?

Yes, the selection process is transparent and unbiased. Names and key details of the winners will be uploaded in the PoleStar Awards website after the awards are declared.

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