2017 Supporting people with cancer Grant initiative

Application Form

[Name of Applicant]

[Project Title]

Closing Date: 14.00 AEDST (Australian Eastern Daylight Saving Time)16 November 2016

One electronic PDF version and one electronic Word version of this application with attachments are to be submitted to email address: applications@canceraustralia.gov.au

and include

‘CA-ITA-1617-01– Grant application’ as the subject of the email.

Faxed or hardcopy applications will not be accepted.

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

people with cancer Grant Guidelines 2017.2. 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.

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 formb) Referee reportsc) Budget annexure 1d) Risk assessment annexure 2.

10. Applications which will be considered for funding must:a) Demonstrate how the proposed project will meet the Grant initiative’s objectivesb) Meet Cancer Australia’s priority target areas by addressing one of the two categories

in the box belowc) Meet the appraisal criteria.

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Grant of up to $120,000 over 3 years (2017-2020)Grant initiative’s Aim and ObjectivesThe Supporting people with cancer (SPWC) Grant initiative aims to reduce the burden of cancer through the provision of grants to community organisations, and encourage effective partnerships between organisations in order to:1. Improve the coordination, accessibility and development of quality cancer support networks2. Better support people affected by cancer3. Focus on local community needs4. Develop innovative approaches to support options5. Build community capability and demonstrate an impact at the health system, community

and consumer level6. Initiate visible partnerships and linkages to services, which will foster appropriate referral to

information and support

2017 Priority Target AreasCancer Australia’s priority target areas for the grants include Australian populations identified as having poorer cancer outcomes. These include:1. People whose outcomes are poorer2. Regional and rural communities3. Aboriginal and Torres Strait Islander communities4. Culturally and linguistically diverse communities5. People who are socioeconomically disadvantaged

2017 Priority Target Areas FrameworkThe priority target areas have been further strengthened with a framework aligned to Cancer Australia’s Strategic Plan 2014-2019. Applicants are required to prepare a project proposal against one of the two categories below and must clearly demonstrate how their proposed project will address one or more of the priority target areas.

Category One: Improving outcomes for people whose outcomes are poorerImprove 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 levelImprove 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.

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Grant applications will be evaluated by an expert Application Assessment Panel through a competitive process.

The panel will use the following appraisal criteria to assess applications:

Item

Grant appraisal criteria Weighting

1 1.1 Ability to meet the Grant initiative’s objectives.

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

1.3 Ability to demonstrate benefit and achieve impact.

10%

10%

10%

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 3.1 Involvement of consumers in the design, development, implementation and promotion of the project.

3.2 Involvement of multidisciplinary champions with a proven track record that can develop evidence-based information/support.

3.3 Demonstration of sustainable strategies throughout and beyond the project period.

10%

10%

10%

4 Innovative/new and unique 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 requirements of the proposal will be assessed on a value for money basis).

unweighted

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 will 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.

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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 10+ 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-1617-01contactofficer@canceraustralia.gov.au

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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.

…………………………………………………………. / /2016(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.

…………………………………………………………. / /2016(Signature of the principal officer submitting this application)

Name:

Position:

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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:

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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. Partner organisations involved in this application (if applicable):

[Note: Organisations may be, for example, affiliates or partners. The Grant initiative encourages effective partnerships to strengthen community networks both locally and nationally, to be robust, reliable and sustainable, and to provide quality support to help people with poorer outcomes.1]

Organisation Name Organisation Address

Organisation ABN 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 2017—including 5.2 (Appraisal criteria) and 2.2 (What can the funding be used for?)— provide a summary of your proposal e.g.:

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

local community health needo New or enhanced information resource and support network to be provided.

1 Australian Government 2015-16 Health Portfolio Budget Statements. May 2015. Cancer Australia Entity Resources and Planned Performance.

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(Limit summary to 2 pages)

Please include

1) Priority area

2) Category (choose one)

Category 1

Category 2

3) Project title:

4) Project objectives:

5) Deliverables/ resources/ output:

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

7) Demonstrated impact assessment (as per 7.1 Grant Guidelines):

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

(Limit summary to 1 page)

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

17. Describe how consumers have been engaged in the development of the project proposal and how they will be engaged in the further design, implementation and promotion of the project. (max 400 words).

18. Describe how your project builds or strengthens linkages/ partnerships within your community and how you will 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).

19. Project need - Describe the evidence to support your project (max 300 words).

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

21. Project methodology - Outline the project governance and project management approach (max 200 words).

22. Project Governance – Please list in the table below information regarding the members of the project steering group (e.g. advisory) and project team (including financial management). Please include relevant experience and technical skills of the members of the team/s.

Project Team

Name Organisation Experience and technical skills

Project Role

Project Steering Group (e.g. advisory)

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technical skills

23. Financial management - What controls will there be on spending project money? Please also complete annexure 1; the Budget template should be used.

24. 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

25. Provide information about other related projects that complement this project.

Organisation Related project

26. Identify key risks including activities that will be undertaken to reduce or remove the identified risks. Please refer to annexure 2 (number 29); the Risk Assessment template should be used.

27/28. 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.

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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

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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 ($) $      $      $     

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29. Annexure 2 Risk Management Plan

RISKSUsing the risk rating guide below, provide a comprehensive list of the potential project risks and the strategies for reducing them.

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 Severe.

CURRENT RISK RATING

Likelihood ConsequencesInsignificant Minor Moderate Major Severe

Almost Certain Medium High High Extreme ExtremeLikely Medium Medium High High Extreme

Possible Low Medium Medium High ExtremeUnlikely Low Low Medium Medium High

Rare Low Low Medium Medium Medium

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Description or risk Likelihood

Consequence

Risk rating Strategies for mitigating risk

Example: Consumer representatives do not support project objectives

Unlikely – Consumers were involved in the development of the application

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

MediumKeep consumer representatives involved at all stages of the project.

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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: Who will benefit from this project?

Question 3: Are you aware of any other networks or organisations which can provide linkages to this project?

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Question 4: Are you aware of any other information resources/support networks that may duplicate this project?

Question 5: Are there any additional comments you may wish to make?

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

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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: Who will benefit from this project?

Question 3: Are you aware of any other networks or organisations which can provide linkages to this project?

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Question 4: Are you aware of any other information resources/support networks that may duplicate this project?

Question 5: Are there any additional comments you may wish to make?

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

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29. Final Application ChecklistBefore submitting your application, please ensure that you have:

• Read and considered the Supporting people with cancer Grant Guidelines 2017• 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 and Word 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 AEDST – Australian Eastern Daylight Saving Time) for the application.

One electronic PDF version and one electronic Word version are to be submitted to email address: applications@canceraustralia.gov.au

and include

‘CA-ITA-1617-01 – Grant application’ as the subject of the email.

Faxed or hardcopy applications will not be accepted.

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