Annex 5: Acceptance Form

The Undersigned, Erlina Burhan, confirms to have read, understood and accepted the terms of the
Request for Proposals (RFP) No. RFP 044-2023, and its accompanying documents. If selected by WHO
for the work, the Undersigned undertakes, on its own behalf and on behalf of its possible partners and
Contractors, to perform RFP template in accordance with the terms of this RFP and any corresponding
contract between WHO and the Undersigned, ☐ for the following sums ☐ P for the amount(s) below and
attached Excel form.

The itemized amounts for each of the deliverables must be completed in the attached Excel form, and must
be uploaded as part of the Financial Proposal. The bidder must ensure that the amount of each Deliverable
or of the total amount is identical in the attached Excel sheet and in Annex 5 below. In case of inconsistency
between those two documents, the most favorable terms to WHO in either the Excel sheet or the Annex 5
shall prevail.

Item Cost*
Deliverable 1: The date of executed agreement 18,866 USD
Deliverable 2: After Kick-off Meeting 12,434 USD
Deliverable 3: After Finalization Workshop 4,011 USD
Deliverable 4: After Dissemination of the Guideline 4,170 USD
TOTAL PROJECT COST 39,481 USD
*UN Operational Rate of Exchange as per 15 March 2023 is IDR 15,372/1 USD

The enclosed Proposal is valid for 180 days from the date of this form (Ref. Paragraph 4.8).

Agreed and accepted, in Jakarta original copies on 10th of April, 2023

Entity Name: Yayasan Riset dan Pelatihan Respirasi Indonesia

Poli Paru Lt.2 RSUP Persahabatan

Mailing Address: Jl. Persahabatan Raya No. 01 RT 016 RW 013 Pisangan Timur, Pulo Gadung, Jakarta Timur
13230

Name and Title of Duty Dr. dr. Erlina Burhan, MSc, Sp.P(K)
Authorized Representative:

Signature:

Date: 10th of April 2023

Request for Proposals: RFP 044-2023

Annex 3: Proposal Completeness Form (Ref. Paragraphs 4.4 & 4.6)

Section Requirements Completed in full (Yes/No)

Annex 2 Confidentiality undertaking form PYes No

Annex 3 Proposal completeness form PYes No

Annex 4 Information about Bidder PYes No

Annex 5 Acceptance form PYes No

Annex 6 Self-Declaration form PYes No

4.12.2 to Technical Proposal, including Executive Summary, proposed

4.12.5 solution, approach/methodology and timeline PYes No

4.12.6 Financial Proposal PYes No

The enclosed Proposal is valid for 180 days from the date of this form (Ref. Paragraph 4.8).

Agreed and accepted, in Jakarta original copies on 10th of April, 2023

Entity Name: Yayasan Riset dan Pelatihan Respirasi Indonesia

Poli Paru Lt.2 RSUP Persahabatan

Mailing Address: Jl. Persahabatan Raya No. 01 RT 016 RW 013 Pisangan Timur, Pulo Gadung, Jakarta Timur
13230

Name and Title of Duty Dr. dr. Erlina Burhan, MSc, Sp.P(K)
Authorized Representative:

Signature:

Date: 10th of April 2023

Project Title / RFP No. 044-2023 Development of National TB and Comorbidities guideline

Description Vol/ Qty Unit Cost Amount

Kick-off Meeting Development of National TB and Comorbidities Guideline

Material
- 1. Stationary 62 pack 1 time IDR75.000 IDR4.650.000
- 2. Photocopy of Document 62 pack 1 time IDR10.000 IDR620.000
- 3. Catridge Printer 0 pcs 0 time IDR0 IDR0
- 4. Banners 3 pcs 1 time IDR100.000 IDR300.000
Expert Fee and Moderator
- Resource Person 2 person 4 hours IDR1.700.000 IDR13.600.000
- Moderator 1 person 4 hours IDR700.000 IDR2.800.000
Transport, Allowance, and Meeting Package
- Local transportation 62 person 1 days IDR150.000 IDR9.300.000
- Daily Allowance 62 person 1 days IDR130.000 IDR8.060.000
- Fullday Meeting Package 62 person 1 days IDR450.000 IDR27.900.000
Zoom Application
Zoom Meeting Package (100 participants) 0 time 0 pack IDR0 IDR0

Meeting for The Development of National TB and Comorbidities Guideline (5 subtopic @1offline meetings x 2 days and 2 online meetings)
Expert Fee and Moderator
- Resource Person (2 person x 2 days x 3 times meeting) 2 person 8 hours 3 times IDR1.700.000 IDR27.200.000
- Moderator (1 person x 2 days x 3 times meeting) 1 person 8 hours 3 times IDR700.000 IDR5.600.000
Transport, Allowance, and Meeting Package
- Local transportation 62 person 2 days 3 times IDR150.000 IDR18.600.000
- Daily Allowance 62 person 2 days 3 times IDR130.000 IDR16.120.000
- Fullday Meeting Package 62 person 2 days 3 times IDR450.000 IDR55.800.000
Zoom Application
- Zoom Meeting Package (100 participants) 1 pack 4 month 1 times IDR145.538 IDR582.152

Workshop to Finalize the Development of National TB and Comorbidities Guideline

Expert Fee and Moderator
- Resource Person 2 person 4 hours IDR1.700.000 IDR13.600.000
- Moderator 1 person 4 hours IDR700.000 IDR2.800.000
Transport, Allowance, and Meeting Package
- Local transportation 62 person 1 days IDR150.000 IDR9.300.000
- Daily Allowance 62 person 1 days IDR130.000 IDR8.060.000
- Fullday Meeting Package 62 person 1 days IDR450.000 IDR27.900.000
Zoom Application
Zoom Meeting Package (100 participants) 0 time 0 pack IDR0 IDR0

Dissemination of National TB and Comorbidities guideline

Material
- 1. Stationary 62 pack 1 time IDR75.000 IDR4.650.000
- 2. Photocopy of Document 62 pack 1 time IDR10.000 IDR620.000
- 3. Catridge Printer 0 pcs 1 time IDR0 IDR0
- 4. Banners 4 pcs 1 time IDR100.000 IDR400.000
Expert Fee and Moderator
- Resouce Person 2 person 3 hours IDR1.700.000 IDR10.200.000
- Moderator 1 person 3 hours IDR700.000 IDR2.100.000
Transport, Allowance, and Meeting Package
- Local transportation 62 person 1 trip IDR150.000 IDR9.300.000
- Daily Allowance 62 person 1 days IDR130.000 IDR8.060.000
- Fullday Meeting Package 62 person 1 days IDR450.000 IDR27.900.000
Zoom Application
Zoom Meeting Package (1000 participants) 1 time 1 pack IDR873.810 IDR873.810
- Package e-certificate send.email 1 time 1 pack IDR0 IDR0

Professional Fee
Team Leader 1 person 4 month IDR15.000.000 IDR60.000.000
Writing team 5 person 4 month IDR10.000.000 IDR200.000.000
Admin support staff 1 person 4 month IDR7.500.000 IDR30.000.000
TOTAL IDR606.895.962
USD 39.481