1. health and fitness
2. disease
3. cancer

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.
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CA-ITA-1415/01 Supporting people with cancer 2015 Grant_Application form
Information and requirements for applicants
1) 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 areas
Cancer 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 poorer
Category 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 level
Category 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; and
2. Meet the 2015 priority areas and address one of the two categories above.
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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; and
d) 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.
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 requirements of the proposal
30%
unweighted
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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 initiative
CA-ITA-1415/01
[email protected]
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VERIFICATION
I 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:
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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. 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
o
o
o
o
o
o
the priority target area and areas of need;
The Category under which your proposal sits;
the existing or new partnership opportunities to extend the range and reach;
the estimated cost and likely timeframe for completion of the project;
the additional consumers who will be supported by the new project;
the new project/resource/linkage to be delivered/ developed and how they will meet local
community health need; and
new or enhanced information resource and support network to be provided.
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(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)
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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 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).
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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
Experience and
technical skills
Project Role
Project Steering Group (e.g. advisory)
Name
Organisation
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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.
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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
inclusive.
(a)
Cost Item
(b)
Brief description of Cost Item
TOTAL ($)
(c)
Estimated
Cost $
I am not a GST-registered applicant – figures provided are GST(d)
Funds sought
from Cancer
Australia $
(e)
(f)
(g)
Organisational Contributions
Contribution
Type
Name of Partner /
Applicant
$
(cash/in-kind)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
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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)
Impact
Low/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.
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TREATMENT STRATEGIES
CURRENT
RISKRATING
ACCEPTABLE/
UNACCEPTABLE?
IMPACT: FROM EVENT
HAPPENING
CONSEQUENCE
SOURCE: HOW CAN
THIS HAPPEN?
LIKELIHOOD
THE RISK: WHAT CAN
HAPPEN?
EFFECTIVENESS
OF CURRENT
TREATMENTS
RISK REFERENCE
29 (a). Annexure 2 RISK MANAGEMENT PLAN
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.
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29 (a cont.) Annexure 2 RISK MANAGEMENT PLAN
LIKELIHOOD
Rate the likelihood of the identified risk occurring with the controls in place.
Ratings are: Almost certain, Likely, Possible, Unlikely or Rare.
CONSEQUENCE
Rate 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
Consequences
Insignificant
Minor
Moderate
Major
Catastrophic
L
M
H
E
E
Likely
L
M
H
H
E
Possible
L
M
M
H
E
Unlikely
L
L
M
M
H
Rare
L
L
M
M
M
Almost Certain
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30. Annexure 3. Referees
REFEREE REPORT
Name
Position
Organisation:
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?
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Question 4: Are there any additional comments you may wish to make?
Signed……………………………………………………………..Date………………………
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31. Annexure 3. Referees
REFEREE REPORT
Name
Position
Organisation:
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.
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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………………………
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29. Final Application Checklist
Before 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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