canceraustralia.gov.au · web viewca-ita-1415/01 supporting people with cancer 2015...

Supporting people with cancer

Grant initiative

CA-ITA-1415/01 Application Form[Name of Applicant]

[Suburb, State/Territory]

Closing Date: 2pm AEDT (Australian Eastern Daylight Time)

22 April 2015

One electronic PDF version of this application with attachments is to be submitted to email address:

[email protected]

and include

‘CA-ITA-1415/01 – Grant application’ as the subject of the email.

Faxed or hardcopy applications will not be accepted.

1CA-ITA-1415/01 Supporting people with cancer 2015 Grant_Application form

Information and requirements for applicants1) Before completing this Application Form, it is required that you read the Supporting

people with cancer Grant Guidelines 2015.2) The information in this application form is provided as guidance only.3) Applications can be made by organisations. There is no requirement to establish a new

legal entity to apply for or receive Grant funding. However, for the purpose of receiving and acquitting funding, where a consortium is involved, a lead organisation must be nominated as the applicant and must be a legal entity.

Grant of up to $120,000 over 3 years (2015-2018)The objectives of this Grant initiative are to:1. continue to build the support available to people affected by cancer;2. improve the quality of support provided to people whose outcomes are poorer, people living

with cancer in regional and rural localities, Aboriginal peoples and Torres Strait Islanders living with cancer, culturally and linguistically diverse communities, and people who are socioeconomically disadvantaged ;

3. improve the dissemination of information and support to people living with cancer and their families, during and after treatment; and,

4. develop linkages to improve access to coordinated, quality cancer support options for all people affected by cancer needing support.

Priority target areasCancer Australia’s priority target areas for the 2015 grants are:• People whose outcomes are poorer • Regional and rural communities• Aboriginal and Torres Strait Islander communities• Culturally and linguistically diverse communities• People who are socioeconomically disadvantaged

2015 Priority Target areas framework (applicants will choose from one category only)

Category One: Improving outcomes for people whose outcomes are poorerCategory one will improve outcomes for people whose outcomes are poor and demonstrate impact at a health systems level and/or community systems level for:• People whose outcomes are poorer • Regional and rural communities

Category Two: Improving support, information and involvement at a local levelCategory two will improve support, consumer involvement and evidence based information at a local level for:• Aboriginal and Torres Strait Islander communities• Culturally and linguistically diverse communities• People who are socioeconomically disadvantaged

The 2015 priority target areas have been further strengthened with a framework aligned to the Cancer Australia Strategic Plan 2014-2019. Applicants will be required to prepare a funding proposal against one of two categories above.

Applications which will be considered for funding must:1. Demonstrate how the proposed project will meet the above objectives of the initiative; and2. Meet the 2015 priority areas and address one of the two categories above.


4) Applicants can only apply for one grant.

5) Applications for funding are open to organisations with a demonstrated track record of supporting people affected by cancer.

6) Organisations that can demonstrate existing or new partnerships (with for example, cancer services, support organisations, universities) are encouraged to apply to strengthen the availability and visibility of consumer information and cancer support networks. One agency must be identified as the lead organisation.

7) You do not need to apply for the whole amount of funding if only a portion of that amount is needed (e.g. If you only need $80,000 you do not need to apply for the whole $120,000). Should you apply for less funds you are still required to meet the criteria. Note that there will be no opportunity to increase the amount of the grant once the application has been lodged. You should consider the specified objectives that must be met if the application were to be successful. Funding will not exceed $120,000 per three year grant and organisations will be required to contribute funding towards the objectives.

8) All applicants will use this application form. The extent of information to be supplied by applicants is indicated in this application form.

9) Applicants should note that applications are made subject to the Conditions of Application and include:

a) ITA application form;b) referee reports;c) budget annexure 1; andd) risk assessment annexure 2.

10)The Application Assessment Panel will use the following selection criteria to assess applications:

Organisations applying under this Grant initiative will be required to demonstrate: Item

Grant selection criteria Weighting

1 Organisations working together, in local and/or national partnerships that demonstrate value and achieve impact (Partnerships may include larger organisations partnering with smaller or non-cancer organisations, for example Aboriginal health services).

30%

2 The project impact and outcome for the priority target areas in one category:Category One will improve outcomes for people whose outcomes are poor and demonstrate impact at a health systems level and/or community systems level and include people whose outcomes are poorer; or regional and rural communities; Or:Category Two will improve support, consumer involvement and evidence based information at a local level and includes Aboriginal and Torres Strait Islander communities; culturally and linguistically diverse communities; or people who are socioeconomically disadvantaged.

30%

3 Capacity building of consumers to facilitate their involvement in the design, development, implementation and promotion of the project and involvement of multidisciplinary champions with a proven track record that can develop evidence based information/support and demonstrate sustainable strategies throughout and beyond the project period.

30%

4 Innovative/new approaches including: consumer involvement in decision making; evidence based information and support options; and flexible/adaptable supportive care models, which avoid duplication of effort and provide linkages and care coordination.

10%

5 Ability to co-fund projects that meet the grant objectives. Should consortiums apply and contribute funding, a lead organisation must be identified. The proposed budget and justification in terms of the

unweighted


requirements of the proposal will be assessed on a value for money basis.

Grant applications will be evaluated by an expert panel through a competitive process. 11) Insurance: Applicants should note that the Australian Government will require grant

recipients to acquire/maintain a certain level of Workers’ Compensation, Public Liability and Professional Indemnity Insurance. Successful applicants may be required to present the relevant certification before contractual arrangements are entered into. Please see Item J and Clause 21of the Cancer Australia draft funding agreement for more information.

12)Compliance with the terms and conditions of the funding agreement: Please carefully review the terms and conditions in the draft funding agreement (provided in the Invitation to Apply) and confirm in Question 12 of the Application Form whether or not you/your organisation can comply with those requirements and if not, why not. You are advised to seek legal advice to confirm your ability to comply with the terms and conditions of the funding agreement.

13)Confidentiality provisions: Please attach a statement to indicate whether any elements of your proposal, which may become part of any subsequent funding agreement, would be regarded as confidential, e.g. commercial in confidence. Please also provide justification for this confidentiality requirement.

14)Declaration of any conflict of interest: Please indicate in Question 13 of the Application Form whether you/your organisation has a conflict of interest or potential conflict of interest that would exist if you/your organisation received funding under this initiative. If a conflict of interest or potential conflict of interest exists, please attach a statement declaring the conflict.

15)Applications must be TYPED using 11+ font size and include page numbers. Handwritten applications will not be accepted.

16)This application must be lodged by email. 17)This application must comply with maximum word limits where they are indicated. Where

there are no word limits identified, box sizes in this application form are indicative only, and may be edited, i.e. the information provided by an applicant may take up more/less space. Where no maximum word limits are required you can add as much information as you think is necessary to help in the assessment of your application.

18)Applicants must complete the application form. Cancer Australia reserves the right to decline to assess applications which do not meet this requirement.

19)Any enquiries about this Grant initiative or the application form must be directed in writing to the Contact Officer at the following email address:

Supporting people with cancer Grant initiativeCA-ITA-1415/[email protected]


mailto:[email protected]

VERIFICATIONI verify that I have checked this application and that, to the best of my knowledge, all relevant details are correct at the time of lodgement.

…………………………………………………………. / /2015(Signature of the principal officer submitting this application)

Name:

Position:

(and, if applicable)

I verify that I have obtained the agreement of the partners and/or co-applicants to this application and have the authority to submit this proposal on their behalf.

…………………………………………………………. / /2015(Signature of the principal officer submitting this application)

Name:

Position:


1. Name of applicant:

2. Registered name (if applicable):

3. Trading name (if applicable):

4. ABN:

5. Organisation Type (e.g. not-for-profit entity, company limited by guarantee):

6. Applicant street address:

7. Applicant mailing address (if the same as street address, please indicate ‘As above’):

8. Contact person for this application:

Name:

Position:

Tel: ( ) Fax: ( )

Email address:

9. Project Sponsor (person with overall business responsibility) (if the same as the contact person for this application, please indicate ‘As above’):

Name:

Position:

Tel: ( ) Fax: ( )

Email address:


10. Project Manager (person with overall project responsibility) (if the same as the contact person for this application, please indicate ‘As above’):

Name:

Position:

Tel: ( ) Fax: ( )

Email address:

11. Other persons/organisations involved in this application (if applicable):

[Note: There is no requirement to form a new legal entity for organisations to jointly apply for funding. Organisations may be, for example, affiliates or partners.]

Person/Organisation Name

Person/Organisation Address

Person/Organisation ABN

Person/Organisation Project role

12. Compliance:

Please review carefully the terms and conditions in the sample funding agreement applicable to the funding stream being sought and confirm whether or not your organisation is compliant with those requirements.

Yes No

13. Conflict of Interest:

Do you/your organisation have a conflict of interest or potential conflict of interest that would exist if you/your organisation received funding under this initiative?

Yes No

If a conflict of interest or potential conflict of interest exists, please attach a statement declaring the conflict.

14. Summary of Proposal

Taking into account the information provided in the Supporting people with cancer Grant Guidelines 2015—including 1.7 (Grant selection criteria) and 2.3 (What can the funding be used for?)— provide a summary of your proposal e.g.:

o the priority target area and areas of need;o The Category under which your proposal sits;o the existing or new partnership opportunities to extend the range and reach;o the estimated cost and likely timeframe for completion of the project;o the additional consumers who will be supported by the new project;o the new project/resource/linkage to be delivered/ developed and how they will meet

local community health need; and o new or enhanced information resource and support network to be provided.

(Limit summary to 1 page)


Please include

1) Priority area

2) Category

Category 1

Category 2

3) Project Objectives:

4) Deliverables/resources/output:

5) Summary of outcomes/benefit to the community to be achieved:

6) Demonstrated impact assessment

15. Demonstrated Track Record - Provide the evidence of your previous experience and outcomes in this area:

(Limit summary to 1 page)

16. Describe your project - What are you planning to do and how are you going to do it? (max 400 words)


17. Describe how your project builds or strengthens linkages within your community or networking consumers with a specific need or population group. In addition, provide evidence of how you will develop and maintain these linkages. (Note: Established or new linkages that facilitate appropriate referral to support networks are critical to the long term success of the project). (max 400 words).

18. Project need: describe the evidence to support your project (max 300 words).

19. Project sustainability: How will the project and its outcomes be self-sustaining beyond the funding period? (max 300 words)


20. Approach: Outline the project governance and project management approach (max 200 words).

21. Project Governance: Complete the tables below of the members of the project steering group (e.g. advisory) and project team (including financial management). Please include relevant experience and technical skills of key members of the team/s.

Project Team

Name Organisation Experience and technical skills

Project Role

Project Steering Group (e.g. advisory)

Name Organisation Experience and technical skills

Project Role

22. Financial management: What controls will there will be on spending project money? Please also complete annexure 1, the Budget template should be used.


23. Provide details of any other organisation/s that has agreed in-principle to contribute either financially or in-kind to the project and any obligations attached to the contribution. Please also complete the section in Annexure 1.Organisation $ Contribution

24. Provide information about other related projects that compliment this project. Organisation Related project

25. Identify key risks including activities that will be undertaken to reduce or remove the identified risks. Please refer to annexure 2, the Risk Assessment template should be used.

26./27. Project management: Please indicate what you plan to achieve including project impact, deliverables and quality of outputs and monitoring project outcomes. Please refer to item 27 table (over page) to complete this question.


27. Project Objectives, Deliverables, Impact & Outcomes, Timeframe

In the table below please provide us with your project’s objectives, deliverables, impact and outcomes and the proposed timeframe

What are your objectives for this project?

What do you plan to achieve? (deliverables)

What are your targets and key performance indicators

How will you know (outcomes and impact) if you have achieved your objectives?

Duration Completion Date

1

2


28. Annexure 1 Budget information

Budget Information – Provide a breakdown of the various project items. Please refer to the guidelines when filling out this section

Please tick the appropriate box below: I am a GST-registered applicant – figures provided are GST-exclusive. or I am not a GST-registered applicant – figures provided are GST-

inclusive.(a) (b) (c) (d) (e) (f) (g)

Cost Item Brief description of Cost Item

Estimated Cost $

Funds sought from

Cancer Australia $

Organisational ContributionsContributio

n$

Type(cash/in-

kind)

Name of Partner / Applicant

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

TOTAL ($) $ $ $


29. Annexure 2 Risk Management Plan

Examples of risk, likelihood, impact and mitigation strategies for the Supporting people with cancer Grant initiative.Risk Likelihood

Low / Med / High(comments)

ImpactLow/Med/High

Mitigation Strategies

Example: Consumer representatives do not support project objectives

Low – Consumers were involved in the development of the application

Med – Consumer involvement is needed for this project in order to reach desired audience

Keep consumer representatives involved at all stages of the project.


29 (a). Annexure 2 RISK MANAGEMENT PLANRI

SK

THE RISK: WHAT CAN HAPPEN?

SOURCE: HOW CAN THIS HAPPEN?

IMPACT: FROM EVENT HAPPENING

TREATMENT STRATEGIES

EFFE

CTIV

ENE

SS O

F CU

RREN

T LI

KELI

HO

OD

CON

SEQ

UEN

CE CU

RREN

T RI

SKRA

TIN

GAC

CEPT

ABLE

/U

NAC

CEPT

ABLE

1

2

3

4

5

6

7

8

RISKS Determine which risks are the most important in terms of their potential to impact on the achievement of the objectives of the project. Where possible, try to combine similar risks to consolidate the number of potential risks.

SOURCE Identify the source of each risk (i.e. how the risk can occur or what would prevent you from achieving the Outcome).

IMPACT Identify the consequence of each risk (i.e. what does it mean to your organisation if it does happen).

TREATMENT STRATEGIES A treatment is a planned approach, process, policy, device, practice or other action that acts to minimise negative


risks or enhance positive opportunities. What are the controls currently in place that affect the impact and/or likelihood of the risk? Controls may include checklists, regular planning meetings, procedures manual, contingency plans, audits or agreements in place.

EFFECTIVENESS OF TREATMENT STRATEGIES An adequate control implies that the risk is well managed and no further treatments are required.A marginally effective control implies that a treatment is not necessary however this may depend on the level of risk.An inadequate control implies that treatments are necessary.

29 (a cont.) Annexure 2 RISK MANAGEMENT PLAN

LIKELIHOODRate the likelihood of the identified risk occurring with the controls in place.Ratings are: Almost certain, Likely, Possible, Unlikely or Rare.

CONSEQUENCERate the consequence to the project outcomes of the identified risk occurring with the controls in place.Ratings are: Insignificant, Minor, Moderate, Major or Catastrophic

CURRENT RISK RATING

Likelihood ConsequencesInsignificant Minor Moderate Major Catastrophic

Almost Certain L M H E ELikely L M H H E

Possible L M M H EUnlikely L L M M H

Rare L L M M M


30. Annexure 3. Referees

REFEREE REPORT

NamePositionOrganisation:Relationship to lead organisation:Length of time of relationship to lead organisation:Contact Phone:Contact Mobile:Contact Email:Contact Fax:

Are you available to be contacted for further information? YES / NO

Question 1: Do you consider this organisation capable of delivering its project?

Question 2: Are you aware of any other networks or organisations which can provide linkages to this project.

Question 3: Are you aware of any other information resources/support networks that may duplicate this project?


Question 4: Are there any additional comments you may wish to make?

Signed……………………………………………………………..Date………………………


31. Annexure 3. Referees

REFEREE REPORT

NamePositionOrganisation:Relationship to lead organisation:Length of time of relationship to lead organisation:Contact Phone:Contact Mobile:Contact Email:Contact Fax:

Are you available to be contacted for further information?YES / NO

Question 1: Do you consider this organisation capable of delivering its project?

Question 2: Are you aware of any other networks or organisations which can provide linkages to this project.


Question 3: Are you aware of any other information resources/support networks that may duplicate this project?

Question 4: Are there any additional comments you may wish to make?

Signed……………………………………………………………..Date………………………


29. Final Application ChecklistBefore submitting your application, please ensure that you have:• read and considered the Supporting people with cancer Grant Guidelines 2015; and• considered the Invitation to Apply for the Supporting people with cancer Grant initiative.

Please check that the following information is included in your application:

Signed verification page

Applicant organisation details pages Confirmation on conflict of interest issues Understanding of the objectives of the Grant

You have attached:

Confidentiality provisions (if applicable)

Declaration of any conflict of interest Risk Assessment (using the template at Annexure 2) Referees (using the template at Annexure 3)

You have provided in the application lodgement package:

Completed electronic application form in PDF version including:

Budget (using the template for Annexure 1)

Risk Assessment (using the template at Annexure 2) Referees (using the template at Annexure 3)

You have checked the closing time (2.00pm AEDT – Australian Eastern Daylight Time) for the application.

One electronic PDF version is to be submitted to email address: [email protected]

and include

‘CA-ITA-1415/01 – Grant application’ as the subject of the email.

Faxed or hardcopy applications will not be accepted.


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