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Stop TB Partner Application Form

Organization Contact Information

Organization Name:
Organization Street 1:
Organization Street 2:
Organization City:
Organization Province:
Organization Post Code:
Organization Country:
Organization Phone:
Organization Email:
Organization Web Site:
 

Focal Point Contact Information

Focal Point Salutation:
Focal Point First Name:
Focal Point Last Name:
Focal Point Title:
Focal Point Email:
 

Stop TB Partner Information

Organization Type:
Organization Description:
 
How did you hear about the Stop TB Partnership:
 
Why do you wish join the Stop TB Partnership:
 
What TB activity\ies are you mainly involved in:

Advocacy, communication and social mobilization

  Health Promotion
  Media
  Patient-led activities and social mobilization
  Political and national advocacy
  TB education and awareness raising

Funding

  Advocacy
  Capacity Building for partner initiatives
  Drugs procurement / distribution
  Health system strengthening
  Research
  TB control

Manufacture of TB products

  1st line adult drugs
  1st line paediatric drugs
  2nd line drugs
  Diagnostics

Research

  Basic research
  Drugs
  Epidemiological
  Health Economics Research
  Health systems, services and policy research
  MDR-TB
  New diagnostics
  Operational Research
  TB/HIV
  Vaccines

TB Healthcare Services

  Community Care
  Diagnostics/Laboratories
  DOTS Expansion
  Drug Provision
  Emergency Relief
  MDR-TB
  TB/HIV
  Workplace services

Technical Assistance

  Advocacy
  Drug Procurement
  Frontline TB Services/ Programme Implementation (operational: treatment and diagnostics)
  Global Fund application
  Human Resources training (Drs, nurses, researchers, NGOs)
  Partnership building
  Research
 
The Seven Stop TB Partnership Working Groups provide a focus for coordinated action. Each of the Working Groups have independent governance mechanisms, but are working under the umbrella of the Stop TB Partnership. We would strongly encourage all partners to participate in the Working Group most relevant to their area of work. For more information on the Working Groups, please click here.
 
Which Working Group(s) will you participate in:
 
No of staff who are directly involved with TB:
 
Which country are you based in:
 
Which country/ies do you do operate in:
 
Which WHO region is the main focus of your work:
 
Are you a member of a Stop TB national partnership:
 
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Confirm Password:
 

Please declare any interests that could constitute a real, potential, or apparent conflict of interest with respect to the Global Partnership to Stop TB.

Conflict of interest means that the prospective member has a financial or other interest that could unduly influence the prospective member's involvement in Stop TB.

An apparent conflict of interest is a financial or other interest that would not necessarily influence the prospective member but could result in the prospective member's objectivity and independence being questioned by others.

A potential conflict of interest is a financial or other interest that any reasonable person could be uncertain whether or not should be reported.

The existence of an appreciable real, potential, or apparent conflict of interest will ordinarily not be used as a criterion to determine membership in the Global Partnership to Stop TB. However, in the case of specific Partnership projects and activities, the Executive Secretary may review the information submitted to assess whether there is an appreciable real, potential, or apparent conflict of interest. A member will be informed if it is felt that the declared interests may disallow participation in a specific project or activity. Members will have the right to appeal to the Coordinating Board for reconsideration.

Information disclosed on this form will not be made available to anyone other than the Executive Secretary of the Global Partnership to Stop TB or his designee.

Declaration of interests

 

  I have read and agree to the Partnership Policy.