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The Alliance of Southern Civil Society in Global Health is an inclusive, transparent, accountable and sustainable platform for Southern CS engagement in health dialogue at country and regional global level. The CS database (developed with support from IHP+, GAVI CS Forum and GHWA), is a product of the 1st Retreat and Dialogue of Southern Civil Society in Global Health in Nairobi Kenya and was created to foster networking, sharing and learning mechanisms for improved communication and engagement between Southern civil society in global health.

Completion of this form is required for membership in Global Health South and its corresponding database.
Full membership is open only to organizations whose headquarters are located in the global south. Observer status is offered to networks, coalitions and umbrella organizations in the global north.

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* 1. CATEGORY OF MEMBERSHIP

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* 2. Please provide the name and contact of the FOCAL PERSON for your organization

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* 3. Name of your CIVIL SOCIETY ORGANIZATION:

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* 4. Location of your Civil Society Organization COUNTRY:

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* 5. Location of your Civil Society Organization COUNTRY REGION:

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* 6. Location of your Civil society organization’s HEADQUARTER COUNTRY:

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* 7. Location of your Organization’s HEADQUARTER COUNTRY REGION:

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* 8. TYPE of Civil Society Organization?

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* 9. Which of the options below best describes your ORGANIZATIONS ORIENTATION ?

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* 10. Which of the options below best describes your ORGANIZATIONS NOMENCLATURE :

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* 11. Please rank each of the following BENEFICIARIES in order of importance of your initiatives and programmes?

  No Engagement(0) Limited Engagment(1) Moderate Engagement(2) Significant Engagement(3)
Neonates and Infants
Under 5 year old
Adolescents and Young Adults (10 - 30 years)
Vulnerable and Socially Excluded Groups
Women (31 - 65 years)
Men (31 - 65 years)

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* 12. Please rank each of the following STAKEHOLDER /FUNDERS GROUP in order of importance of your initiatives and programmes?

  No Engagement(0) Limited Engagement(1) Moderate Engagement(2) Significant Engagement(3)
Community Leadership/Organisation
Sub National Policy Makers & Funders
National Policy Makers & Funders
Continental (Regional) Policy Makers & Funders
Global Policy Makers & Funders

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* 13. Please rank your organization’s GEOGRAPHICAL COVERAGE for activities mentioned in Question 12.

  No Engagement(0) Limited Engagment(1) Moderate Engagement(2) Significant Engagement(3)
Community
Sub National
National
Continental (Regional)
Global
All of the above

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* 14. Please rank the FUNCTIONAL CLASSIFICATION of your organization in each of the listed activities :

  No Engagement(0) Limited Engagment(1) Moderate Engagement(2) Significant Engagement(3)
Service Delivery
Policy advocacy and Dialogue
Research, Evidence and Performance Management
Capacity Enabling and Technical Support
Leadership Development
Accountability
Sustainable Environment
Civil, Human Security and Rights
Innovation

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* 15. Which of the following best describe your organizations ACTIVITY CLASSIFICATION ?

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* 16. Please rank the level of engagement of your organization in each of the listed areas.

  No Engagement(0) Limited Engagment(1) Moderate Engagement(2) Significant Engagement(3)
Health Systems
Disease Specific
Issue Specific

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* 17. If you indicated interest in HEALTH SYSTEMS, please rank your level of engagement in each of the following activities .

  No Engagement(0) Limited Engagment(1) Moderate Engagement(2) Significant Engagement(3)
Financing
Human Resources
Health Information Systems
Medicines and Medical Supplies
Procurement, Logistics & Supplies Chain Management
Quality Management and Improvement
Performance Monitoring and Evaluation
Diagnostics and Critical Care
Policy and Strategy Development
Community Organization and Engagement
Accountability

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* 18. If you indicated interest in DISEASE SPECIFIC AREAS, please rank your level of engagement in each of the following activities .

  No Engagement(0) Limited Engagment(1) Moderate Engagement(2) Significant Engagement(3)
Malaria
Tuberculosis
HIV/AIDS
Non Communicable Diseases
Neglected Tropical Diseases

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* 19. If you indicated interest in ISSUE SPECIFIC AREAS, please rank your level of engagement in each of the following activities.

  No Engagement(0) Limited Engagment(1) Moderate Engagement(2) Significant Engagement(3)
Nutrition
Gender
Sexual and Reproductive Health
Maternal, Newborn and Child
Adolescent Health and Youth Empowerment
Population and Development
Primary Health Care
Vaccines and Immunization

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* 20. Which of the following do you or your organization BELONG to?

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* 21. Which of the following do you or your organization SUPPORT/ACTIVE in delegation?

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* 22. Please indicate which of the following programmes of Global Health South is your organization interested in participating and contributing in the context of strategic and work plan for 2013 - 2015.

Declaration
Should there be any change in the information I have provided will promptly notify Global Health South of the relevant changes to update its database.


Thank for your completing this form. For additional information, please contact communications@chestrad-ngo.org

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