Peace Corps Volunteer Report

Country: Name of Project:

This report covers activity in which

VID #:
fiscal year (Oct 1 - Sep 30)?
Peace Corps
Volunteer Name: Trimester 1: Oct, Nov, Dec, Jan
Trimester 2: Feb, Mar, Apr, May
Hyperlinks to report worksheets Trimester 3: June, July, Aug, Sept
Tell your story (community integration, lessons learned, etc)
Activity tracking sheet Trimester
Mass media activities
Counterpart Feedback
Volunteer and APCD feedback
Other information

Worksheets to be filled out once per year at end of fiscal year

Total participants (only report once at end of year)
Agency initiative area summary (only report once at end of year)

Appendices to this reporting tool

Project framework (purpose, goals, objectives)
Definitions
Questions to help measure outcomes
COMMUNITY INTEGRATION:
How integrated do you feel in your community? (Place an X in the box that best represents how
integrated you felt during the period.)
Somewhat
Not integrated Integrated Well integrated Gone native
integrated

Please provide more detail about your community integration

(How is your language learning going? What have you learned about cross-cultural integration? Do you
have any suggestions for training based on your community integration experiences?)

VOLUNTEER SUCCESS STORY!

Please provide a short (2-3 paragraph) description of your work in meeting the goals of this project, or describe a 'secondary'
activity. In writing, try to show the positive difference you and your counterparts have made in your community. (If you are
completing this manually, attach extra sheets as needed.)

CHALLENGES: What challenges have you faced in your project or in other areas of your Peace Corps experience?

LESSONS LEARNED: Describe lessons learned about your project, your community or yourself.

ACTIVITIES PLANNED FOR NEXT 3 TO 4 MONTHS:

PEACE CORPS GOAL TWO: " to help promote a better understanding of the American people on the part of the
peoples served…"

If you have done something with your community to promote a better understanding of Americans--of your own cultural
heritage, of American ideals you care passionately about, etc--please describe below what you did.

PEACE CORPS GOAL THREE: " to help promote a better understanding of other peoples on the part of the
American people."

If you have done something to promote more understanding back home about aspects of life in your community here, please
describe below what you did.

2
3
SAFETY/SECURITY
How safe to you feel at home and at work? (Place an X in the box that best represents how safe
you felt during the period.)

Always feel safe Occassionally feel unsafe Often feel unsafe

Please provide more detail about your safety and security concerns, if any:

COMMUNITY PARTNERS
Please provide information on new community partners you worked with during this reporting period. You don't have to list the same
partners you've reported previously. The purpose of this section is to help provide us with a fuller understanding of the organizations present
in your community, to help us build a better profile of the community over time, and to help us understand who the resources are that future
Volunteers might want to link with.
Name Title/Organization Contact Information Area of Cooperation

4
Brief description of the activity (What Output of activity (What was the Select the project
short-term output of the activity? objective number Individual Individual Individual Individual
did you do? What was the purpose of the Number of Number of
E.g. a new strategic plan for an or 'secondary men (25 and women (25 boys girls
activity? Who participated in the activity? org's communities
organization; a revised curriculum activity' from the older) and older) (15-24) (15-24)
What's the name of the group?) for teachers) drop down list
Brief description of the activity (What Service Service Service Service
Individual Individual Service Service If the activity had an HIV-AIDS focus, select
did you do? What was the purpose of the Provider Provider Provider Provider
boys girls Provider provider from the drop-down list the indicator that
activity? Who participated in the activity? (under 15) (under 15) men women boys girls boys girls best applies.
What's the name of the group?) (15-24) (15-24) (under 15) (under 15)
Brief description of the activity (What Output of activity (What was the Select the project
short-term output of the activity? objective number Individual Individual Individual Individual
did you do? What was the purpose of the Number of Number of
E.g. a new strategic plan for an or 'secondary men (25 and women (25 boys girls
activity? Who participated in the activity? org's communities
organization; a revised curriculum activity' from the older) and older) (15-24) (15-24)
What's the name of the group?) for teachers) drop down list
Brief description of the activity (What Service Service Service Service
Individual Individual Service Service If the activity had an HIV-AIDS focus, select
did you do? What was the purpose of the Provider Provider Provider Provider
boys girls Provider provider from the drop-down list the indicator that
activity? Who participated in the activity? (under 15) (under 15) men women boys girls boys girls best applies.
What's the name of the group?) (15-24) (15-24) (under 15) (under 15)
Brief description of the activity (What Output of activity (What was the Select the project
short-term output of the activity? objective number Individual Individual Individual Individual
did you do? What was the purpose of the Number of Number of
E.g. a new strategic plan for an or 'secondary men (25 and women (25 boys girls
activity? Who participated in the activity? org's communities
organization; a revised curriculum activity' from the older) and older) (15-24) (15-24)
What's the name of the group?) for teachers) drop down list
Brief description of the activity (What Service Service Service Service
Individual Individual Service Service If the activity had an HIV-AIDS focus, select
did you do? What was the purpose of the Provider Provider Provider Provider
boys girls Provider provider from the drop-down list the indicator that
activity? Who participated in the activity? (under 15) (under 15) men women boys girls boys girls best applies.
What's the name of the group?) (15-24) (15-24) (under 15) (under 15)
 Go to Main Menu Go to project framework Go to Activity Tracking Sheet

Outcome indicators (These indicators describe participant outcomes we Select the project
Total within the
are trying to achieve in this project. They are intended to ease recording objective number
Baseline Data fiscal year (Oct Change
of key changes you have observed or measured in the knowledge, skills, from the drop
1 to Sept 30)
attitudes, behaviors, or condition of project participants.) down list

0
 Go to Main Menu Go to project framework Go to Activity Tracking Sheet

Outcome indicators (These indicators describe participant outcomes we Select the project
Total within the
are trying to achieve in this project. They are intended to ease recording objective number
Baseline Data fiscal year (Oct Change
of key changes you have observed or measured in the knowledge, skills, from the drop
1 to Sept 30)
attitudes, behaviors, or condition of project participants.) down list

0
 Go to Main Menu Go to project framework Go to Activity Tracking Sheet

Outcome indicators (These indicators describe participant outcomes we Select the project
Total within the
are trying to achieve in this project. They are intended to ease recording objective number
Baseline Data fiscal year (Oct Change
of key changes you have observed or measured in the knowledge, skills, from the drop
1 to Sept 30)
attitudes, behaviors, or condition of project participants.) down list

0
 Go to Main Menu Go to project framework Go to Activity Tracking Sheet

Outcome indicators (These indicators describe participant outcomes we Select the project
Total within the
are trying to achieve in this project. They are intended to ease recording objective number
Baseline Data fiscal year (Oct Change
of key changes you have observed or measured in the knowledge, skills, from the drop
1 to Sept 30)
attitudes, behaviors, or condition of project participants.) down list

0
 Go to Main Menu Go to project framework Go to Activity Tracking Sheet

Outcome indicators (These indicators describe participant outcomes we Select the project
Total within the
are trying to achieve in this project. They are intended to ease recording objective number
Baseline Data fiscal year (Oct Change
of key changes you have observed or measured in the knowledge, skills, from the drop
1 to Sept 30)
attitudes, behaviors, or condition of project participants.) down list

0
 Go to Main Menu Go to Activity Tracking Sheet Mass media activities or other events where attendance was too large to count

Report your best estimate of the total number of individuals reached through mass media activities or events where attendance
was too large to count. These events could include radio broadcasts, public theatre, printed materials distributed at a market, a
television broadcast, etc. If you did not conduct any mass media activities, leave this section blank.

Description of mass media activity or event (please note in your Estimated If it was an
number of HIV/AIDS
description the project objective number that this activity supported, if individuals activity, Who is your contact person for this kind
applicable) reached select 'yes' of mass media activity? Please include
contact information (phone, e-mail)
Community Partner Feedback
Please tell us what is going well in your collaboration with your PCV, as well as any concerns or challenges you may be
having.

Community Partner Signature Date

Supervisor Feedback
Please review this report and write your feedback below.

Supervisor Signature Date

PCV Feedback to Peace Corps
Please use this space for anything you would like to request / discuss / share with your APCD at this time.

This section is not intended to be shared with your counterpart or supervisor.

PCV Signature Date

APCD FEEDBACK to Volunteer

Please provide feedback to volunteer based on each section of the report.

APCD Signature Date

 Go to Main Menu Other Information

Other 1 Please use this space to raise any questions/concerns or suggestions for the CD or PTO.

Other 2 Please indicate if your health has impacted your ability to do your job during the reporting period.

Other 3 If any national issues have impacted your service thie period, please describe them here.

19
 Go to Main Menu Total Fiscal Year Project Participants

COMPLETE THIS WORKSHEET JUST ONCE PER YEAR AS PART OF FOR YOUR FINAL REPORT OF THE
FISCAL YEAR (from October 1 through September 30).

As part of your final report on the fiscal year just ended (Oct 1 through Sept 30), please
enter below the total number of project participants you worked with over the year. To
avoid counting the same person, organization or community more than once, refer to your
'individual activity tracking book' and tally up all the 'first-time' participants within the fiscal
year. Please do not include estimates of indirect beneficiaires, or of individuals reached
through mass media activities. The numbers below are supposed to include all the people,
organizations, and communities you reached with direct, capacity-building kinds of
activities.

Number of participating
Number of participating individuals and
organizations and
service providers
communities
Boys Girls
Men Women Organizations Communities
under 25 under 25

Individuals

Service
providers
 Please describe your work during the past fiscal year
Go to Main Menu in Peace Corps' 4 "Initiative" areas: HIV, ICT, go to HIV/AIDS go to ICT go to WID/GAD go to Youth
WID/GAD, and Youth

COMPLETE THIS WORKSHEET JUST ONCE PER YEAR AS PART OF FOR YOUR FINAL REPORT OF THE
FISCAL YEAR (from October 1 through September 30).

1. HIV/AIDS Prevention and Care

Are you involved in any HIV/AIDS activities?

Please indicate which type of HIV/AIDS activity you have conducted, if any. Enter 'yes' next to each type of
activity in which you have been involved.

Prevention activities (A, AB, other)

Care for people living with AIDS (PLWA) and their families

Care for orphans and vulnerable children (OVC)

Training service providers

Strengthening organizations/providing technical assistance to

organizations

Other (please describe briefly)

If applicable, please provide an example of how you have integrated HIV/AIDS activities into your work
assignment.
Are you involved in an HIV/AIDS task force?
2. Information and Communication Technology
Are you involved in any ICT activities?

Which kind of ICT activity BEST describes the main focus of your work in ICT? (put a 'yes' next to just one of
the types of ICT activities listed below)

Radio/Audio
TV/Video
Computer Skills
Internet- or web-based instruction or training

Assisted community to set up and manage a computer lab in a community or school

Assisted community in obtaining computer equipment

Assisted community in obtaining Internet connectivity

Other (please describe):

If applicable, please provide an example of how you integrated ICT activities into your work assignment.

Please list titles of any ICT materials you have developed or contributed to.
Videos
Tape recordings
Printed matter
Other materials
3. Women in Development/Gender and Development (WID/GAD)

Please provide an example of how you have integrated gender into your work assignment.

What tools, if any, did you use to integrate a gender and development approach into your primary work
assignment? Type a 'yes' next to each tool you have used.

Participatory Analysis for Community Action (PACA)

Participatory Rural Appraisal (PRA)
Gender Analysis
The Gender Analysis Matrix in PDM
Daily activity schedule
Seasonal calendar
Community mapping
Priority ranking
Other (Please describe below):
4. Youth Development

Please provide an example of how you have integrated youth development into your primary work
assignment.

If you have developed any youth development materials, tools, or resources please describe them below.
Go to Main Menu Disenfranchised and low-income communities in the Eastern Caribbean have improved
their quality of life by -transforming from recipients of aid into partners in change,
reducing HIV/AIDS prevalence rates, improving overall health, and enhancing
Purpose: educational and employability skills.

Goal One

Targeted groups and organizations will increase their abilities to identify, evaluate,
Goal 1:
develop, and implement solutions to community priorities

By Sept 2011, Vs and community partners will have trained 300 community leaders and
Objective 1.1 managers of organizations, including small businesses and those addressing HIV/AIDS,
on participatory assessment tools or PACA.

By Sept 2011, Vs and community partners will provide technical assistance to 30

Objective 1.2
communities in developing or improving existing community development plans.

By Sept 2011, Vs and community partners will train and assist 100 community
organizations in implementing the priorities outlined in their community development
Objective 1.3
plans by providing technical assistance in project development, project implementation,
operational procedures, IT use, and monitoring & evaluation.

By Sept 2011, Vs and community partners will have trained and/or assisted 150
community leaders and managers of organizations and small businesses, including
Objective 1.4
those addressing HIV/AIDS, on organizational strengthening tools such as the “NGO
Capacity Profile Tools”.

GOAL TWO
Community members including in & out of school children and youth will improve their
Goal 2: learning through exposure to innovative teaching methods and participation in
community service programs

By Sept 2011, Vs and community partners will have trained and assisted 200 educators
Objective 2.1
on special education methodologies.

Objective 2.2 By Sept 2011, Vs will co-teach 1,500 special education students.

By Sept 2011, Volunteers and community partners will have raised awareness and
Objective 2.3
advance the interests of children, youth, and adults with special needs.

By Sept 2011, Vs and community partners will have provided basic literacy and
Objective 2.4 remedial education to 5000 youth and adult students in their communities and train
1000 service providers.
By Sept 2011, Vs and community partners will have exposed 500 children and youth to
Objective 2.5 character education programs including the Virtues, sports, and music programs aimed
at strengthening self confidence and reducing deviant behavior.

By Sept 2011, Vs and community partners will have provided training to 300 children,
Objective 2.6
youth, and adults on Information Technology and Communication tools.

By Sept 2011, Vs and community partners will have increased community involvement
Objective 2.7
in local voluntary activities.

GOAL THREE

Communities will develop and implement behavior change interventions targeting

Goal 3: prevention of HIV/AIDS and 6 chronic diseases and support to those living with the
diseases.
 By Sept 2011, Vs and community partners will have trained 200 community leaders and
Objective 3.1 managers of organizations on Behavior Change Communication (BCC) and/or Behavior
Change and Information (BCI) methodologies

By Sept 2011, Vs and community partners will have disseminated information to 2000
Objective 3.2 community members, on HIV/AIDS FACTS in regards to prevention, support, and
stigma & discrimination.

By Sept 2011, Vs and community partners will have trained 300 youth and children on
Objective 3.3
Life Skills.

By Sept 2011, Vs and community partners will have participated in the creation and/or
Objective 3.4 strengthening of an HIV/AIDS network of NGOs to promote effective collaboration on
the implementation of the National AIDS Plan.
 DEFINITIONS OF TERMS
Go to Main Menu
Go to Activities Worksheet
Go to HIV/AIDS definitions below

Activities. Activities include the major areas of work Volunteers undertake to achieve a project's objectiv
include, for example, delivering teacher training workshops, organizing farmer cooperatives, or assessing
health service needs. In reporting activities and outputs, include in your description:
--the number of Volunteers engaged in the activity
--the immediate outputs of those activities.

For example:
"5 PCVs and their counterparts co-facilitated 20 workshops for youth leaders to increase their knowledge
and malaria) prevention practices."

or,
"11 PCVs and their counterparts organized local water committees in 22 communities and held one round
gather information about wat/san needs."

Participant. A participant is an individual, service provider, organization or community who participates i

primary or secondary activities. Participants are considered direct beneficiaries, since they interacted d
Volunteer.

Indirect beneficiary. An indirect beneficiary is someone who did not participate in a Volunteer activity,
benefited from the activity. For example, an Education Volunteer trains 10 teachers in improved teaching
trained teachers go on to use the new teaching methods in the classroom, which results in improved stud
this case, the students would be indirect beneficiaries, since they benefited from the Volunteer activity, ev
Volunteer didn't work with the students directly. Indirect beneficiaries should be reported in the outcome
appropriate objective, and not in the capacity building tables

Capacity building levels. Capacity building levels describe the four main groups that Volunteers assist
individuals, service providers, organizations, and communities.

Individuals. Individuals are people that Volunteers assist or reach directly, for example, community me
farmers, or small business owners.

Service Providers ("Persons Trained"). Service providers are people Volunteers assist or train, who in tu
services to others. Examples of service providers could include teachers, health clinic workers, communit
educators, etc. Volunteer activities that build capacity at this level could include teacher training worksho
worker trainings, for example.
Organizations. Organizations include schools, governmental or non-governmental organizations (NGOs)
based organizations (CBOs), health clinics, informal community groups, associations, cooperatives, and ot
Organizational capacity building activities might include assisting an organization with strategic planning,
management, or strengthening organizational policies or systems.

Communities. Communities are groups of people living in the same geographic area, usually a village o
Community capacity building activities typically have a community focus, such as raising awareness about
environmental issues affecting a community. If a Volunteer works with members of a community, that Vo
report assisting that community as well as the community members.

Outcomes. Please report the outcomes of the activities and related outputs described under ‘activities.’
CHANGE in knowledge, skills, attitude, behavior, or condition of project participants and their communitie

If an activity has not yet led to an outcome; or if the Volunteer(s) can not state with some confidence tha
contributed to the observed outcome, please leave the 'outcome' space blank.

Sample outcome statement:

“50 youth leaders demonstrated an increased understanding of how to prevent malaria and HIV transmiss
by pre and post knowledge tests."

or,
"8 communities changed their behavior regarding control of potable water by developing plans to improve
water and presenting them to municipal health officials.

DEFINITIONS for HIV/AIDS ACTIVITIES AND TRAINING

Activities to promote abstinence or be faithful (AB). Activities or programs that promote abstinence
the:

Importance of faithfulness in reducing the transmission of HIV among individuals in long-term sexual partn

Elimination of casual sex and multiple sexual partnerships;

Development of skills for sustaining marital fidelity;

Adoption of social and community norms supportive of marital fidelity and partner reduction using strateg
and respond to local customs and norms; and

Adoption of social and community norms that denounce forced sexual activity in marriage or long-term pa

Activities to promote abstinence only (A). Activities or programs that only promote the:

Importance of abstinence in reducing the prevention of HIV transmission among unmarried individuals;

Decision of unmarried individuals to delay sexual activity until marriage;

Development of skills in unmarried individuals for practicing abstinence; and

Adoption of social and community norms that support delaying sex until marriage and that denounce forc
among unmarried individuals.

NOTE: Abstinence only (A) is a subset of abstinence and/or be faithful (AB)

Activities beyond primarily abstinence and/or be faithful messages ("other")

Other activities aimed at preventing HIV transmission including purchase and promotion of condoms, sexu
infections (STI) management (if not in palliative care settings/context), messages/programs to reduce inj
and related risks.

Organizations include governmental or nongovernmental organizations (NGOs), community-based organ

faith-based organizations (FBOs), as well as informal community groups, associations, and cooperatives.

Technical assistance to organizations includes activities that build capacity of organizations, such as org
development (building management skills, developing organizational skills and materials, improving recor
systems), stigma and discrimination reduction workshops, community mobilization activities, and grief an

Orphans and Vulnerable Children (OVC) Care is any medical, psychological, spiritual, or social suppor
OVC, including school-related support. OVC care includes activities to improve lives of children (under 18
directly affected by AIDS by strengthening communities to meet needs of orphans and vulnerable children
community-based responses, helping children and adolescents by training caregivers, increasing access to
economic support, and adding food and nutrition interventions.

Palliative Care is any medical, psychological, spiritual, or social support provided to PLWA and families.
includes all clinic based and home/community-based activities to improve quality of life of HIV-infected cli
families through management of infections such as malaria and HIV/AIDS related complications, as well a
support, legal aid, housing, training and support for caregivers.

People Living With AIDS (PLWA). Clients infected with HIV/AIDS. Same as PLHA, PLWHA, PHA.

Training of Service Providers means training activities that build the knowledge and skills of service pr
nurses, caregivers, clinic workers, youth peer educators, community health care professionals, other med
teachers, NGO leaders, managers of cooperatives, and other leaders. Training includes such events as wo
conferences, and one-on-one coaching. To qualify as a training event, there must be a curriculum and exp
objectives or expected competencies to be acquired.

Prevention activities include programs, services, and activities to help prevent transmission of HIV/AID
community outreach, peer education, classroom and small-group education, and sexually transmitted infe
management services.
 Attendance Sheet

Name of activity:

Date of activity:

Obj. # or secondary activity:

Location of activity:

Other Individual
Participant's Name of Name of under or
information Sex or Service
Name organization community over 25?
(e.g.nickname) Provider?
 Attendance Sheet

Name of activity:

Date of activity:

Obj. # or secondary activity:

Location of activity:

Other Individual
Participant's Name of Name of under or
information Sex or Service
Name organization community over 25?
(e.g.nickname) Provider?
 Attendance Sheet

Name of activity:

Date of activity:

Obj. # or secondary activity:

Location of activity:

Other Individual
Participant's Name of Name of under or
information Sex or Service
Name organization community over 25?
(e.g.nickname) Provider?
 Attendance Sheet

Name of activity:

Date of activity:

Obj. # or secondary activity:

Location of activity:

Other Individual
Participant's Name of Name of under or
information Sex or Service
Name organization community over 25?
(e.g.nickname) Provider?
 Attendance Sheet

Name of activity:

Date of activity:

Obj. # or secondary activity:

Location of activity:

Other Individual
Participant's Name of Name of under or
information Sex or Service
Name organization community over 25?
(e.g.nickname) Provider?
Go to Main Menu

Outcome indicators (These indicators describe participant outcomes we are

trying to achieve in this project. They are intended to ease recording of key Question or Measure for Outcome Indicators (e.g. For 1.1.c. "Name one new skill you gained from
changes you have observed or measured in the knowledge, skills, attitudes, the training that you have used in the past 6 months."
behaviors, or condition of project participants.)
 OFFICE OF COMMUNICATONS
AUTHORIZATION TO USE PERSONAL MATERIAL

I, , hereby grant to the Peace Corps a perpetual, worldwide, royalty-free,

license to use, reproduce, or publish, for purposes authorized by the Peace Corps Act: my name; the negative
photographs, videotapes, and/or other audio or visual recordings of myself; my articles and stories; and any ot
documents, writings, statements, recordings, representations, or information I may provide pursuant to and in
with the terms of this Authorization.

In particular, I hereby authorize the Peace Corps to use, reproduce, or publish any or all of the above-listed ite
make reference to me in connection with these items to promote the Peace Corps using various media and pub
including, but not limited to: websites; books; public service advertising on television and radio stations; telev
broadcasts; direct mail pieces; print advertisements; brochures; flyers; posters; articles; editorials; speeches;
discussions; radio interviews; and television programs.

I acknowledge that I will receive no compensation from the Peace Corps in consideration of this Authorization o
the above-listed items pursuant to this Authorization.

Name

Signature Date