Mental Health and Alcohol and Other Drug ServicesCapital Grant Program

Facilities Renewal GrantMental Health Safety and Privacy Grant

Grant Application Form

Contents1 Appendix 2: Application form...................................................................................................................... 11.1 CEO’s declaration........................................................................................................................................... 11

1 Appendix 2: Application form

Submission requirements:

Due Date: 30 November 2015 – 4pm

All organisations making submissions must complete this application form and include relevant supporting documentation (for example: cost plans; quotations).

Proposals must be received no later than 30 November 2015 – 4pm to be eligible for consideration. Proposals must be submitted by electronic copy only. Late, incomplete, facsimiled, hand delivered or Proposals delivered by mail will not be accepted.

All submissions must be submitted via electronic copy to mhdcapital@dhhs.vic.gov.auAll Proposals will receive a confirmation email upon receipt.

Proposals:Services are required to denote the priority order of each application. Note: Only one property per application form.

Unless exceptional circumstances apply, proposals received after the specified time and date are deemed ineligible for consideration. Services that fail to meet the deadline as a result of IT failure will not be subject to any special considerations. To avoid such issues, services are encouraged to submit Proposals prior to the due date.

Please ensure:

The application form is submitted as a word document.

The CEO declaration is completed and submitted as a scanned electronic document (e.g. PDF); electronic signatures will not be accepted.

the file attachments have the following naming convention:

Service Name_Project Title_ Application no. 1 or 2.doc

Service Name_Project Title_CEO Declaration.pdf

Service Name_Project Title_Attachment 1.doc/pdf

(repeat as required for multiple attachments).

The Department of Health & Human Services reserves the right to request additional supporting information in relation to any application submitted to the Mental Health and Alcohol and Other Drug Services Capital Grant Program.

As this is a capped program not all eligible Proposals will be funded. To meet community expectations it is anticipated that funding will be used to support a broad range of communities and organisations.

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 1

Mental Health and Alcohol and Other Drug Services Capital Grant Program – (2015/16)

Please Note: All figures are to be shown exclusive of GST

Grant Type: Please Circle only one

Mental Health Facilities Renewal GrantAlcohol and Other Drug Facilities Renewal GrantMental Health Safety and Privacy Grant

Organisation name:[Press F11 to move to next field] [Please complete all fields]

Project Title     

Address Number Street Name Suburb State Postcode

Project Address                   VIC      

Property owner

Land Type (i.e Crown or Freehold)

Service/s provided

TOTAL GRANT FUNDS requested.(Ex. GST)

CO-INVESTMENT(Ex. GST)

TOTAL PROJECT VALUE(Ex. GST)

$      $      $

Service Priority (select)Priority 1 2 3 4 5 6 7

Services are required to denote the priority order of each grant proposal.

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 2

1. Organisation Details

Name Details

Legal Name      

Trading Name      Australian Business Number (ABN):      

Type of Organisation      Funded Service Provision type/s      Will entity/entities responsible for managing the delivery of the project also own and maintain the resulting assets? If not, name the entity/entities that will own and maintain the resulting assets.

     

2. Organisation Address

Address Number Street Name Suburb State PostcodeStreet Address                   VIC      Postal Address

[PO Box]

      VIC      

3. Authorised contact officers

Name Title Phone Preferred Contact

[Insert Name] Chief Executive Officer [xx xxxx xxxx]

Email:      @     

Alternative Contact(s)

[Insert Name] [Insert Title] [xx xxxx xxxx]

Email:      @     

[Insert Name] [Insert Title] [xx xxxx xxxx]

Email:      @     

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 3

4. Service - Background[Insert a brief description of the background of the service] [Please limit the response in this field to less than 250 words]

5. Project SummaryProvide a brief description of the project, please ensure that key deliverables are specified. This field will be used to provide summary reports on projects submitted. 250 words maximum.

6. Key Deliverables<Please ensure deliverables are made explicit (ie. to replace the roof, create 2 additional consult rooms, 2 additional beds, replace 2 window frames, replace the 10 outlet heating system etc>

7. Project Objectives[Insert details of how the project supports current service and strategic planning objectives]

8. Project Activities[Insert details outlining the scope of the proposed capital works project

[Detailed descriptions of the works to be undertaken]

For example: A minor capital works project should outline the following information as a minimum with additional relevant information provided as required:Key Deliverables (eg. extra consult rooms, m2 of refurb/redevel, specific detail of what existing conditions are and what will be delivered through the completion of the works).Size/dimensions of area to undertake worksCurrent condition of building fabric and/or equipmentDetails of the capital works to be undertaken (i.e.minor refurb: paint work/ carpets/ furnishings, water, gas, electricity, heating, cooling or structural works, compliance to standards, disability access)What planning has been undertaken to date for the proposed capital works

Please note; details in relation to proposed costs should be included in the cost plan template, located in section 22 of the application form. The cost plan must be completed for all projects.

9. Existing Conditions

[Outline the existing conditions]

10.Current status of planning/’readiness’ [Outline the current status of planning which will enable the project to meet proposed timelines]

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 4

11.Equipment Details (where applicable)

Equipment Intended Purpose Quote Price(s)(attach quote/s)

                                                   

12.Project Rationale

[Insert details of rational of the proposed project. It should outline the action that needs to be considered at this time. This should capture the essence of why the project is required and the consequences of deferral.]

13.Project Urgency

[Insert details outlining the urgency of the project and implications of not undertaking the project. Please specifiy timelines if necesary]

14.Relationship to existing infrastructure

[Insert details of how the proposed capital project and/or equipment relates to the existing infrastructure of your facility]

15.Recent capital projects

Capital Project Details Funding Source Date Completed

[Insert brief details of recent capital projects undertaken at the project address in the past 1-10yrs]

           

16.Project Management & Capacity to undertake Project

[Insert details outlining the proposed project management of the proposal by your service. If the project management is to be undertaken by the service, please list resources and personnel]

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 5

17.Project Risk Management

All projects are required to complete the following table. Further lines should be included as required for any additional risks identified.

Risk Impact Likelihood Mitigation Strategy

Cost estimates are too low [High/Medium/Low]

[High/Medium/Low]

[Insert details]

Project delay [High/Medium/Low]

[High/Medium/Low]

[Insert details]

Costs are not included [High/Medium/Low]

[High/Medium/Low]

[Insert details]

Unacceptable operational disruption during implementation

[High/Medium/Low]

[High/Medium/Low]

[Insert details]

Delays in Authority approvals [High/Medium/Low]

[High/Medium/Low]

[Insert details]

Inadequate Programming or Program delays

[High/Medium/Low]

[High/Medium/Low]

[Insert details]

Cost problems – budgeting inadequacies

[High/Medium/Low]

[High/Medium/Low]

[Insert details]

[Other - Insert as required] [High/Medium/Low]

[High/Medium/Low]

[Insert details]

18.Project Timelines

Key Activity (Milestone) Key Date % Funding Distribution[Insert activity/milestone] [Insert date] [% Funding]

[Insert activity/milestone] [Insert date] [% Funding]

[Insert activity/milestone] [Insert date] [% Funding]

[Insert activity/milestone] [Insert date] [% Funding]

[Insert activity/milestone] [Insert date] [% Funding]

Note: Services are requested to align % funding distribution with key activities/milestones as appropriate to the projects size and/or complexity.

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 6

19.Funding Proposal (GST Exclusive)

Funding Source 2015/16 ($m)(ex. GST)

Mental Health and Alcohol and Other Drugs Renewal Grant

$     

Organisation contribution $     Other co-contribution (Source:      ) $     Mental Health Safety and Privacy Grant $     Organisation contribution $     Other co-contribution (Source:      ) $     Total $     

20.Consultation

It is expected that proposed projects have been developed in consultation with the relevant central office program area and/ or regional office of the Department of Health & Human Services.

Please provide details of the consultation and/or endorsement of the proposed project, including details of a key contact(s), as follows:

[Insert details of consultation with the relevant program area and whether endorsement of the proposed proposal has been granted]

[The area below is for completion of who within the Department of Health & Human Services you have discussed your proposed project with.

Key Department of Health & Human Services contact(s)Name [Insert Name] Phone [Insert Phone number]Title [Insert Title] Email      @     

DH [Insert Program Area/Reg Office Details]

Name [Insert Name] Phone [Insert Phone number]Title [Insert Title & Program Area] Email      @     

DH [Insert Program Area/Reg Office Details]

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 7

21.Alignment with the grant program Assessment Criteria

Criterion One The application demonstrates alignment with the aims of the grant program, the organisation's designated role, long-term strategy, and Victorian Government policy.

[Please ensure that under each criterion, you provide a succinct summary of how your project relates to the criterion]

Criterion Two The application includes sufficient supporting documentation to demonstrate need and priority, and is well researched, strategic and justified to avoid delays in the construction/purchase of equipment in the event of grant approval.

[Please ensure that under each criterion, you provide a succinct summary of how your project relates to the criterion]

Criterion Three The application demonstrates that local consumer and carer representatives are involved or consulted in regards to the project.[Please ensure that under each criterion, you provide a succinct summary of how your project relates to the criterion]

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 8

22.Cost Summary

There are two available costing summaries (a) and (b).

Cost plan (a) – is designed to be used for projects where a simple list of project costs is sufficient to outline the costs of the project (i.e. under $100,000).

Cost plan (b) – is designed to be used for minor capital works (i.e. refurbishment/redevelopment) where a detailed cost plan is more appropriate. This should be completed for any refurbishment/redevelopment projects.

Only one cost summary should be completed – please choose the most appropriate one for your project.

All costs should be shown exclusive of GST

Cost Plan (a)

Item Cost (ex GST)

Quote provided (Y/N)

Total

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 9

Cost Plan (b)

To be completed for all projects which involve minor capital works including construction and/or refurbishment.

Cost Plan Summary - [Insert Project Title] – [XX/Month/Year]Based on [Insert Detail] Completed by: [Completed by:]

Functional Area Scope Area (m2 Rate ($/m2) Total (ex GST) ($)

[Insert Detail - Eg. Kitchen]                        [Insert Detail - Eg. bedroom]                        [Insert Detail - Eg. Primary Care]                        

                       Total Building CostsProject Specific CostsAllowance for [Demolition]Allowance for [Site Works]Allowance for [Asbestos Removal]

Design Contingency      %Contract Contingency      %Cost Escalation Allowance to Tender at [Insert Date]      %

Total Construction Cost (at Insert Date)Other Project Costs[Specialist Equipment][IT and Communications][Consultants Fees][Sustainability & Infrastructure][Management Support][Relocation costs][Authority Charges]Quotes provided

Total End Cost (at Insert Date)

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 10

1.1 CEO’s declaration

Service Project Title[Insert Service] [Insert Project Title]

Declaration

I [Insert CEO Full Name] Chief Executive Officer of [Insert SERVICE Name] , declare that the information provided on the Mental Health and Alcohol and Other Drugs Facilities Renewal/ Mental Health Safety and Privacy Grant proposal and supporting documentation is complete and correct and I confirm my understanding that:

Where multiple projects are proposed by a service, these have been prioritised at the service level as indicated in the proposal.

The proposed minor capital works: have not already commenced or completed construction; if relating to equipment, the equipment has not already been purchased, is not second hand equipment; and does not involve the payout of lease, currently leased or acquisition as part of a consumable contract.

No additional recurrent funding will be sought from the Department of Health & Human Services for the minor capital works proposal. Any recurrent funding implications in relation to the minor capital works will be absorbed by the service.

Any funds provided for the proposed minor capital works will not be used for any other purpose than that for which the specific grant is made. If the proposed funds are insufficient to complete the project, the Victorian Government is not obliged to provide additional funding.

If other contributing organisations fail to provide funding, the Victorian Government is not obliged to provide this funding. The Organisation will be responsible for organising the funding in question.

The minor capital works proposed are in accordance with National Construction Code (NCC)/Building Code of Australia (BCA) requirements, Australian Standards and Statutory Requirements and where applicable the Victorian Design Guidelines and include as far as practical the relevant sustainability guidelines. Equipment items (where applicable) must comply with relevant Australian Standards.

The equipment requiring replacement will be disposed of and this will be in accordance with appropriate standards. The service asset register will be updated for both the disposal of the old equipment and the acquisition of the replacement item.

In accordance with the standard service agreement terms and conditions, the service indemnifies the Department of Health & Human Services against a claim by any person for loss of or damage to property, death or personal injury or other financial loss, caused by the negligence of, or breach of, statutory duty by the service provider.

If funded, the service will show the minor capital works grant as having been committed and expended on capital works (and/or equipment where applicable), in accordance with the respective grant approvals, by inclusion in its annual report to the Department of Health & Human Services.

The funding request and associated costings/quotations are provided exclusive of GST.

CEO [Insert CEO Name] Phone [(xx) xxxx xxxx]Date [Insert Date] Mobile [xxxx xxx xxx]Signature Email [xxxx@xxxxx]

Note: This declaration must be signed by the CEO and emailed to the Department of Health & Human Services as a scanned copy of the original (eg. PDF). Electronic signatures will not be accepted.

[Insert Health Service Name][Insert Project Title]The Department of Health & Human Services Mental Health and Alcohol and Other Drug Services Facilities Renewal Grant 2015-16Mental Health Safety and Privacy Grant 2015-16 11