FD Centre — FD Centre Triage & Prioritisation Form

1 REQUEST IDENTIFICATION

Request ID *

National Society (NS) *

Country *

Region *

Request Title *

Date Received *

Triage Officer *

Linked Request Form *

2 ELIGIBILITY SCREENING All must be "Yes" to proceed

NS consent received Leadership buy-in Within FD scope Sufficient information submitted Sponsor identified (if required) Conflict of interest check

3 SCORING SCORECARD Score 1–5 for each dimension

Dimension	Definition	Score (1–5)					Weight (%)	Weighted Score	Comments
		1	2	3	4	5
TOTAL WEIGHTED SCORE (max 100)							100%	0.00

Outcome band

Each dimension scored 0–5; weighted score = Σ(score ÷ 5 × weight), max 100. Routing: A 80–100 · B 65–79 · C 50–64 · Out < 50. A red flag can block a high score (risk overlay).

4 INTERVENTION SELECTION

Recommended Modality

Remote In-Person Hybrid

Estimated Effort Level

Required Team Composition

Likely Region Lead *

Technical Lead Review *

5 DECISION RECOMMENDATION

✓Approve for Needs AssessmentProceed to Step 4 ⚡Fast TrackExpedited intervention ⏸Hold Pending InformationMore information required ✕Reject / Out of ScopeDoes not meet eligibility or scope ↷Refer to PartnerRefer to another partner or mechanism

Decision Rationale / Key Notes *

0 / 1000

6 APPROVALS & SIGN-OFF

Regional FD Manager — Name

FD Centre Director — Name

Decision

Date