hif application form strand 1 round 2 - pobal.ie · web viewclosing date for applications ......

Application form Strand 1

Local Communities for a Healthy Ireland 1 April 2018 to 31 March 2019

CLOSING DATE FOR APPLICATIONS

Friday 11th May 2018 @3pm

Please read the application guidelines before completing this form

Contact Pobal Email: [email protected]

mailto:[email protected]

LCDC/CYPSC Details

1 Enter your Pobal Unique Reference Number (URN).If you do not have a URN write N/A

2 Enter the name(s) of LCDC or CYPSC

3 Enter the total amount of grant requested.If you are a LCDC the grant must not be greater than €75,000If you are a CYPSC the grant amount cannot be greater than €37,100

For joint application €112,100 for an LCDC & CYPSC application €150,000 for joint LCDC application €74,200 for joint CYPSC application

€

Primary contact details within the LCDC or CYPSC for this project.

3 Name of primary contact person within LCDC or CYPSC

4 Role within LCDC or CYPSC

5 Telephone and e-mail for the LCDC or CYPSC primary contact person

Mobile

Landline

E-mail

Nominated lead organisation details

Please provide the details below in respect of the organisation you have nominated to enter into the grant agreement/contract with Pobal.6 Legal name of the nominated grant agreement

(contract) holder.

7 If the contract guarantor has a current grant agreement with Pobal, please enter their URN.

8 Legal structure of the contract guarantor Choose an item.

If you choose “other” please explain

9 Address of nominated lead organisation

10 Name of contact person within the nominated lead organisation

11 Position/role of the nominated lead contact person

12 Telephone and e-mail contact details for the nominated lead contact person

Mobile

Landline

Email

13 Companies Registration Number (CRO)

14 Tax Registration Number (TRN)

15 Tax Clearance Access Number (TCAN)

16 Registered Charity Number (RCN)(If applicable and issued by the Charities Regulator).

17 CHY Number(If applicable and issued by the Revenue Commissioners)

All grantees (successful applicants to Healthy Ireland) must comply with DPER Circular 13/2014 – Management of and Accountability of Grants from Exchequer Funds. For more information go to: http://circulars.gov.ie/pdf/circular/per/2014/13.pdf

Address 1

Address 2

Address 3

Town

County

EIRCODE

http://circulars.gov.ie/pdf/circular/per/2014/13.pdf

Governance and management structures 18 What are the governance arrangements and operational structures for the

management of the grant requested and the delivery of the actions outlined? Outline any sub-committee and or advisory committee(s) to your board which are in place or will be

put in place to govern and manage the delivery of each action in this application form. Include details on how often committee(s) will meet, who is represented on each committee and who

is accountable and to whom. You may submit a chart or diagram with this application form to demonstrate your reporting and

accountability structures for these actions. A template is available.

19 Outline the written agreement(s) e.g. a partnership agreement, a memorandum of understanding, that are in place or will be put in place with your partner(s) and implementing organisations responsible for the delivery of each action(s) or specific activities within one or more actions.

20 What are the financial management arrangements for the implementation of your proposed actions? Include a summary of the internal controls, management of the budget, accounting and financial

reporting in respect of the overall grant applied for. Explain your arrangements for the disbursement of funds for each action and/or to a partner(s) or

other collaborative organisation

21. Actions for a Healthy IrelandList the key actions in the table below that will raise awareness of the positive benefits of physical activity and or promote wider participation in physical activity. The maximum number of actions that a CYPSC can apply for is 6. The maximum number of actions that a LCDC can apply for is 8. For joint applications the maximum number of actions that can be applied for is 12Information Required ExplanationTitle Provide a name for each key action Repeat or New Action

Tell us if this a repeat of an action undertaken in the previous round of funding or a completely new action

Rationale for a repeat action

Tell us the benefits of the original action and any independent evidence of the benefits in the context of the Healthy Ireland Framework and the key reasons why you want to repeat this action or part of an action.

Action type You must select an action type. The action type reflects the relevant “HIF Initiative” which your action falls under. There are 3 options to choose from and you can only select one option as follows: (A) Healthy Ireland Strategic Plan i.e. an action related to the development of a Healthy Ireland Strategic Plan (B) Local priorities for health and wellbeing e.g. an action related to the implementation of your Healthy Ireland Strategic Plan and (C) Membership of Healthy Cities and Healthy Counties Network of Ireland (LCDCs only) e.g. any action that will result in an LCDC fulfilling the requirements to become a member of the Network.

Description Action in the context of this application, describes a group of common activities at the highest level and may include one discrete activity or a set of common activities/steps to achieve a common goal. Actions may be standalone activities or may be a component that adds value to any existing programme or project.

Milestones and timeline

Identify the significant phases of work in relation this action and provide key milestones with indicative dates. Please note that milestones will be included in your grant agreement and progress will be monitored against these milestones.

Target group(s) Tell us who will directly benefit from each action, in particular highlight any vulnerable groups of people. Vulnerable groups for the purpose of this fund are: Children, young people and adults living in areas of social-economic disadvantage; Children, young people and adults with disabilities and or chronic illnesses (including mental health issues); Unemployed young people and adults; Children, young people and adults from new communities (including asylum seekers and refugees); Children, young people and adults from the travelling community; Children, young people and adults from other minority groups e.g. LGBTI; older people.

Geographic area Tell us which areas will directly benefit from each action. Local (e.g. town, neighbourhood, area); county, multiple counties, region, organisation e.g. primary/secondary schools, third level institutions, libraries, sector e.g. early years

Action co-ordinator Tell us the name of the organisation and job title of the person within the organisation who is responsible for ensuring that the action happens and all tasks associated with the action are undertaken.

Partners Tell us about any partners (formal and informal) involved in the planning and delivery of this action e.g. public, private, community/voluntary organisations, statutory sector, independent charitable organisations, youth organisations, sports organisations, healthcare organisations, business sector, education and training institutions, organisations representing specific target groups. All actions must have a cross-sectoral approach to planning or delivery. Indicate if this an existing partnership arrangement or new arrangement for this round of funding.

Outputs Tell us what anticipated results will be achieved immediately after implementing this action. e.g. how many people will benefit from the action and from which target group e.g. all population, unemployed young people and adults; how many people will be involved; how many organisations will be involved; how many organisations will benefit from the action; include the type of benefit anticipated e.g. an improvement in outdoor exercise/recreational facilities; awareness of a specific aspect of health and wellbeing e.g. physical health and wellbeing; mental health and lifestyle, walking and cycling; drugs and alcohol; food, nutrition and weight management, sexual health, smoking and tobacco;

Information Required Explanationgeneral physical activity, sport and fitness; swimming and water based activities

Alignment with Health Ireland Framework and other relevant government policies or action plans.

Tell us how the action will complement or contribute to objectives and actions outlined in the Healthy Ireland – A Framework for Improved Health and Wellbeing 2013-2015. For information go to the Healthy Ireland website. In particular outline how the action is aligned to the National Physical Activity Plan, the National Sexual Health Strategy, Tobacco Free Ireland, the Obesity Policy and Action Plan

LECP or CYPP actions and your Healthy Ireland Strategy

Local Economic Community Plans (LECPs) and Children and Young People’s Plans (CYPPs). All actions must be clearly linked to actions in the current LECP or CYPP. Indicate if your plan is currently in draft or has been signed off by your committee. If you have a local Healthy Ireland Strategy in place, please indicate this in your response and explain how your action is clearly linked to your Healthy Ireland Strategy.

Procurement Tell us about your intentions in terms of procuring goods and services in relation to this action e.g. tendering, sub-contracting for each activity within the action.

Total cost of this action

Complete the budget template sent to you with this application form. Insert the total cost for each action in the table below. Please ensure that the figures correspond to the figures in the budget template. Note: There is a minimum budget threshold of €5,000 per action.

http://www.healthyireland.ie/

Action 1When you click on “choose item” in the tables below, a list of dropdown options will appear. You can select one item only. The table has no character or word limits however please be as concise as possible in your responsesInsert a title for Action 1 Is this a new

action or a repeat action?

Choose an item.

Select action type Choose an item.

Start Date for the action Click here to enter a date. End date for the action Click here to enter a date.Provide a succinct description of the action and list the key milestones.

Description

Milestones Note: These will be included in your grant agreement and progress will be monitored

Date to be completed by

1 Click here to enter a date.








If this is a “repeat action” please provide a rationale for repeating this action.List the target group(s) for this action.

Geographic area that will benefit from this action

Action co-ordinator: Insert the name of the organisation, job title/role responsible.What partners are involved in the planning and delivery of this action?

List the output(s) for this action.

Demonstrate how this action aligns with the Healthy Ireland Framework and other relevant government policies, strategies and action plans.

Demonstrate how this actions aligns with your LECP or CYPP and your Healthy Ireland Strategy, if one is in place.Tell us how you intend to procure the services or goods required to implement this actionDoes this action require the employment of staff?

Choose an item. If yes enter job title and submit the job description template with this application form

Enter the total cost for this action.Must be equal to €5,000 or more

€



Choose an item.



Description











If this is a “repeat action” please provide a rationale for repeating this actionList the target group(s) for this action.

Geographic area that will benefit from this action :

Action co-ordinator: Insert the

name of the organisation, job title/role responsibleWhat partners are involved in the planning and delivery of this action?






€



Choose an item.



Description


















Choose an item. If yes enter job title and submit the job description template with this application form.


€



Choose an item.



Description

















Demonstrate how this actions aligns with your LECP or CYPP and your Healthy Ireland Strategy, if one is in place.Tell us how you intend to procure the services or goods required to implement this action.Does this action require the employment of staff?



€



Choose an item.



Description




















€



Choose an item.



Description

















Demonstrate how this actions aligns with your LECP or CYPP and your Healthy Ireland Strategy, if one is in place. Tell us how you intend to procure the services or goods required to implement this actionDoes this action require the employment of staff?



€



Choose an item.



Description











If this is a “repeat action” please provide a rationale for repeating this actionList the target group (s) for this action.





Demonstrate how this action aligns with the Healthy Ireland Framework and other relevant government policies and action plans.

Demonstrate how this actions aligns with your LECP or CYPP and your Healthy Ireland Strategy, if one is in placeTell us how you intend to procure the services or goods required to implement this actionDoes this action require the employment of staff?

Choose an item. If yes enter job title and attach job description template to support this application


€



Choose an item.



Description











If this is a “repeat action” please provide a rationale for repeating this action.List the target group (s) for this action.





Demonstrate how this action aligns with the Healthy Ireland Framework and other relevant government policies and action plans.

Demonstrate how this actions aligns with your LECP or CYPP and your Healthy Ireland Strategy, if one is in place.Tell us how you intend to procure the services or goods required to implement this action.Does this action require the employment of staff?

Choose an item. If yes enter job title and attach job description template to support this application

Enter the total cost for this action.Must be equal to €5,000 or more.

€

If you wish to insert another action, you may copy and paste an action table here.

Reminder:

The maximum number of actions that a CYPSC can apply for is 6. The maximum number of actions that a LCDC can apply for is 8. For joint applications the maximum number of actions that can be applied for is 12

22 Explain how you intend to monitor and record progress in relation to all actions, to ensure that they are completed by the end of March 2019?

23. Project budget

Please complete the budget template provided with the application form and ensure that you provide a detailed explanation for each cost applied for.

Please note the following when preparing your budget.

You are required to provide an explanation for each of the costs applied for under each action

Core costs of your organisation or the nominated organisation for the grant agreement are not eligible. For example, rent, light and heat, ICT, insurance, service charges, core staff costs, central administration costs.

Small pieces of equipment for seconded staff such as a laptops are not eligible. All costs included in the budget must be directly related to the implementation of the

project proposed and verifiable i.e. at a later date the expenditure incurred must be supported by evidence such as an invoice. You are not required to submit quotations or tender information with your budget, as part of the application process.

You are required to follow public procurement guidelines in implementing this project proposal and to set up specific accounting records for this funding round.

Capital works and routine repairs of buildings and equipment are not eligible

Refer to the application guidelines for a more detailed list of eligible and ineligible costs.

Please include a clear explanation and justification for each cost applied for on the budget template

Additional information24 Please provide any other information which you think is relevant to this application

25. Documents required to be submitted with your application formIf attached

please insert “x”

Hyperlink to

website(optional)

1 Organisational Chart for the governance and management of the project (Optional- Template Provided)

☐

2 Job Description Template (Mandatory if staff costs are included in the budget template)

☐

3 Budget Template (Mandatory) ☐

4 If you have updated LECP or CYPP please submit with your application or insert hyperlink to a website page for download by Pobal

☐

26. Disclaimers

A. Disclosure under the Freedom of Information Act

Under the Freedom of Information Act 2014, the information in this application form and its attachments may be released on request to third parties.

If you believe that any of the information in your application form is sensitive and should not be disclosed to a third party, you must identify the sensitive information and provide the reason(s) for its sensitivity.

You will be consulted about the sensitive information before any decision is made to release the information to a third party.

Please outline the sensitive information and the reason(s) for the sensitivity in the text box below.

Text box (maximum 1,500 characters). Optional.

B. Data Protection

In submitting this application to Pobal, your organisation (and project partners) agree that:

No sensitive personal data should be included on this form. Sensitive personal data is defined as data relating to a person's racial origin; political opinions or religious or other beliefs; physical or mental health; sexual life; criminal convictions or the alleged commission of an offence; trade union membership. In this case, sensitive personal data may also refer to the inclusion of names, addresses and/or ages of service users or project beneficiaries in your application form.

Your organisation authorises Pobal to use, process and store the information in this form for the purposes of assessing your proposal for funding, the administration of any grants awarded by the Healthy Ireland Fund and the production of internal and external reports relating to the Healthy Ireland Fund.

In its management of the Healthy Ireland Fund, Pobal may transfer any data it has received from, and any data it holds relating to your organisation to other persons and bodies, such as the Department of Health.

If a third party is acting on your organisation’s behalf, Pobal is authorised to use, process and store data received from this third party and to forward to the third party, any data relating to your application, Pobal’s appraisal of your application and your organisation’s delivery of projects supported by the Healthy Ireland Fund. Pobal may also procure data from third parties to assess your application.

It is your organisation’s responsibility to ensure that any sensitive personal data submitted is obtained with the individual’s consent and knowledge that the data will be used for the purposes of this application. By submitting this application form, your organisation confirms that consent has been obtained from any individual whose data is disclosed within the application form.

Tick box to confirm that you have read and agree with the above data protection requirements.

27. SUBMISSION OF APPLICATION

Please read carefully before submitting your application.

The LCDC or CYPSC by submitting this application:

Confirm that the application form and attached documents is submitted on their behalf; Declare that the information provided in the application form and attached documents are

true and accurate; Accept that Pobal may contact funding organisations or government departments to

discuss this application and previous funding awarded, as part of the selection process; Has the co-funding in place as described in the application form (if applicable); Accept that the Department of Health or Pobal shall not be liable to the applicant or any

other party in respect of any loss, damage or costs of any nature arising directly or indirectly from:

a) The application or the subject matter of the application;b) The rejection for any reason of any application.

Accept that the Department of Health or Pobal, their servants or agents, shall not at any time or in any circumstances, be held responsible or liable in relation to any matter whatsoever arising in connection with the development, planning, construction, operation, management and or administration of an individual project.

Confirm that the costs applied for are not retrospective costs i.e. expenditure that has already occurred.

Confirm that should the application be successful will the nominated contracting body will comply with the DPER Circular 13/201.4 – Management of and Accountability for Grants from Exchequer Funds. http://circulars.gov.ie/pdf/circular/per/2014/13.pdf

Name

Position on the Committee

See link to Pobal’s Privacy Statement and Acceptable Use Policy

https://www.pobal.ie/Publications/Documents/Privacy%20Statement%20and%20Acceptable%20Use%20Policy.docx

http://circulars.gov.ie/pdf/circular/per/2014/13.pdf