TASMANIAN HEALTH ASSISTANCE PACKAGE: BETTER ACCESS TO PALLIATIVE CARE IN TASMANIA PROGRAM INVITATION TO APPLY FOR FUNDING ITA No.

TASMANIAN HEALTH ASSISTANCE PACKAGE: BETTER ACCESS TO PALLIATIVE CARE IN TASMANIA PROGRAM INVITATION TO APPLY FOR FUNDING ITA No. DoHA/273/1213 Instructions for Submitting Applications. Closing Date Applications close at 2:00PM Australian Eastern Daylight Time on 30 MAY 2013 (Closing Time). How to lodge Submit your Application at Part D by courier or hand deliver to: Better Access to Palliative Care in Tasmania Program ITA No. DoHA/273/1213 Department of Health and Ageing Tender Box Sirius Building, Foyer, Ground Floor, 23 Furzer Street WODEN ACT 2606 You must provide SIX unbound & unstapled copies of your Application. NOTE: The Tender Box is accessible for deliveries between the hours of 8:30am and 2:00pm Monday to Friday (public holidays excepted). Do not hand deliver to the security guard. Applications are to be lodged in the tender box by the Applicant or authorised representative. Receipt of Application Receipt of Application Form will be acknowledged by email from the following address: bapc@health.gov.au Late Applications The Department will only accept your Application if it is late as a direct result of mishandling by the Department. In all other circumstances, in the interests of fairness, the Department reserves the right not to accept late Applications. In considering whether it would be fair to accept a late Application, the Department will take into account the degree of lateness, whether the cause of the lateness was beyond the Applicant's control and such other facts as it considers relevant. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 1

Invitation to Apply for Funding The Department may also ask the Applicant to provide evidence to support its claims regarding the reasons for late submittal. If the Applicant considers that their Application will be late they should notify the Contact officer prior to the Closing Time advising of the circumstances for the lateness. The Chair of the Assessment Committee will take the reasons into consideration when deciding whether or not to accept the late Application. Contact Officer All enquiries relating to this Invitation to Apply for Funding under the Better Access to Palliative Care in Tasmania Program should be directed via email to bapc@health.gov.au ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 2

Invitation to Apply for Funding STRUCTURE OF THIS INVITATION TO APPLY PART A GENERAL INFORMATION FOR APPLICANTS PART B ASSESSMENT OF APPLICATIONS PART C HOW TO APPLY FOR FUNDING PART D APPLICATION FORM SECTION 1: CONDITIONS OF PARTICIPATION AND MANDATORY / THRESHOLD CRITERIA SECTION 2: APPLICANT DETAILS SECTION 3: FUNDING REQUEST / ASSESSMENT CRITERIA SECTION 4: ACKNOWLEDGEMENTS SECTION 5: DECLARATION PART E FREQUENTLY ASKED QUESTIONS ATTACHMENT A BETTER ACCESS TO PALLIATIVE CARE PROGRAM GUIDELINES ATTACHMENT B FUNDING AGREEMENT (TEMPLATE) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 3

Invitation to Apply for Funding - Part B PART A - GENERAL INFORMATION FOR APPLICANTS 1. Background 1.1. On 15 June 2012, the Minister for Health, the Hon Tanya Plibersek announced a $325 million Tasmanian Health Assistance Package (THAP) for Tasmania s health system, outlining a number of significant investments to ease pressures and equip Tasmania s health system to meet future challenges. 1.2. The Better Access to Palliative Care in Tasmania (BAPC) program is a key element of the THAP. The aim of the BAPC program is to enhance the provision of community based palliative care using innovative methods, with an emphasis on providing patient centred packages of wrap-around palliative care for people in the final 12 months of life. 1.3. The program is administered by the Department of Health and Ageing (the Department). You can find more information about the BAPC program on the Department s website by visiting www.health.gov.au 2. Program Value and Funding Objectives 2.1. The Australian Government will provide up to $42.85 million (GST inclusive) over the period 2013-14 to 2015-16 through this Invitation to Apply (ITA) to implement the core service delivery component of this program. Funding will comprise: Component 1: Packages of Community Based Palliative Care $39.33 million (GST inclusive) to deliver packages of customised wrap around care with a focus on 24 hour/after-hours access to community based palliative care, carer and family support services including equipment and specified bereavement services (where there is an identified need); and Component 2: Infrastructure Support and Enablers $3.52 million (GST inclusive) to provide vital infrastructure support services including (but not limited) to health promotion, volunteer training, professional development training and capacity building. 2.2. Applicants are eligible to apply for funding to undertake activities through both Component 1 and Component 2. Applicants may apply for only one Component if they choose. 2.3. Consortium based approaches are encouraged and will be given priority for funding where it can be established that the proposed approach will deliver enhanced community based palliative care services across multiple or all regions of Tasmania, including rural, regional and remote locations. 3. Policy Context 3.1. The Program Guidelines have been developed to underpin the operation of the program and articulate the program s policy objectives, operating parameters, eligibility criteria and compliance requirements. A copy of the Program Guidelines is at Attachment A. 4. What Will Be Funded? 4.1. In order to support a patient centred approach, the Department is not prescribing a comprehensive list of activities and services, however, it is expected that the funding will be awarded for activities such as (but is not limited to): ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 4

Invitation to Apply for Funding - Part B Component 1 on the ground palliative care clinical services in people s home/usual place of residence; other infrastructure that supports existing services to enhance the delivery of home based care; palliative care specialist consultation services; after-hours and 24/7 services and support including outreach services in rural/remote areas; patient support services, including care navigation/case management services; carer/family centred support services, including after-hours advice/support services and limited specified bereavement services; respite care; and domestic support services. Component 2 Activities to commence immediately: resources; volunteer training and education, including the development of health professional education and training, including but not limited to activities that attract continuing professional development points; and other capacity building activities not already identified. Activities to commence from 2014-15 in consultation with DHHS and THOs: health promotion activities relating to death, dying, end of life care and bereavement including health professional, patient, carer and community awareness raising such as advance care planning; and identified. Other health promotion/ healthy dying activities not already 5. What Will Not Be Funded? 5.1. Activities not eligible for funding are specified at Section 2.3.2 of the Program Guidelines at Attachment A. 6. Who Can Apply for the Funding? 6.1. Organisations eligible for funding are specified at Section 2 of the Program Guidelines at Attachment A. 6.2. Applicants must demonstrate that they can foster a strong working relationship with the Department of Health and Human Services (DHHS) in order to deliver packages of wrap around palliative care and implement the outcomes and objectives of the BAPC program. 6.3. Applicants must demonstrate that they have or can quickly acquire strong links with Tasmania s existing network of palliative care providers, including primary care, specialist palliative care, aged care and community services sector. 6.4. Successful applicants will be required to work with an independent program evaluator appointed by the Department for the duration of the program as stipulated by the Department. 6.5. For legal and accountability reasons, only incorporated bodies are eligible to apply for funding under this program. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 5

Invitation to Apply for Funding - Part B 6.6. All existing private and non-government providers of palliative care services in Tasmania are eligible to submit an application for funding. 6.7. Applicants are not required to have had a prior funding relationship established with the Department, but must be a legal entity to be eligible for funding. 6.8. The Department encourages organisations to form collaborations, consortia or partnerships to deliver this project. 6.9. If more than one organisation will be involved in the project, identify one organisation as the lead organisation and an authorised representative of the lead organisation must sign the Application Form. 7. Timeframes 7.1. The Department anticipates that successful funding Applicants will be selected in line with section 1.7 of the Program Guidelines at Attachment A. 7.2. The Department will contact the successful Applicants after they have been selected to discuss the preparation of the Funding Agreement. 7.3. The Department may not notify unsuccessful Applicants until it has executed Funding Agreements with the successful Applicants. 7.4. Funding will be distributed to the successful Applicants in line with section 1.7 of the Program Guidelines at Attachment A. Funds made available under the BAPC program must be expended by 30 June 2016. 7.5. The funding period will commence in line with section 1.7 of the Program Guidelines at Attachment A. 8. Funding Agreement 8.1. The successful Applicant(s) will be required to sign a Funding Agreement with the Commonwealth, represented by the Department, before receiving any funding. 8.2. The Schedule to the Funding Agreement will provide a detailed description of the activities to be provided in the project, these details will be based on the information provided in your Application. Funding payments will be based on ongoing satisfactory performance in line with the Funding Agreement. The Schedule will provide a breakdown of the respective funding to be paid throughout the life of the project. 8.3. Applicants should note that, if they are successful, some details of their project (including a project outline, their name and the amount of funding awarded) will be made public and posted on the Department's website as part of Department s legislative reporting obligations. 8.4. The Funding Agreement at Attachment B will form the basis of the Terms and Conditions offered by the Department to successful applicants. Any partial or noncompliance issues should be disclosed as part of your proposal / application. Where no partial or non-compliance issues are identified, it will be taken to be compliant with the Terms and Conditions of the Funding Agreement. 9. Insurance 9.1. All Applicants should ensure that they have in place, or if successful will be required to obtain and maintain for the period specified in the Funding Agreement, all types and amounts of insurance necessary to cover the obligations of the organisation in relation to the BAPC program. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 6

Invitation to Apply for Funding - Part B PART B - ASSESSMENT OF APPLICATIONS 1. How Will the Applications for Funding Be Assessed? 1.1. All proposals will be assessed against the criteria described in Section 2 of the Proposal Form by an Assessment Committee according to the Assessment Plan. 1.2. The Assessment Committee will consist of officers from the Department. Other representatives with relevant expertise may provide advice and/or technical assistance to the Assessment Committee as required. 1.3. The selection process will be undertaken in two stages: 2. Stage 1 - Conditions of Participation 2.1. Each applicant must satisfy Part D, Section 1 of the Application Form that specifies the Conditions of Participation in order to be considered for funding. The Assessment Committee will determine whether the applicant satisfies all the Conditions of Participation requirements. Only applications that satisfy all Conditions of Participation will proceed to Stage 2 and be considered further by the Assessment Committee against the criteria in Part D Section 3 Funding Request 3. Stage 2 Assessment Criteria 3.1. Further assessment will be made against the criteria specified in Part D, Section 3 Application Form. 3.2. The Assessment Committee will undertake assessment of applications and will consider the applicant s response to each Assessment Criterion specified in Part D, Section 3 Application Form using a 5-point (0 to 4) scale (see Table 1 below). Table 1: Five-point rating scale to be used against Assessment Criteria Rating Excellent Quality excellent claims against the criterion, exceeds expectations, information provided confirms consistent superior performance Very good quality very good claims against the criterion, meets all expectations to a high standard with complete and comprehensive information provided Good quality good claims against the criterion, meets all expectations with convincing information provided Poor quality poor claims against the criterion, does not meet expectations, may be lacking detail and/or information provided Marginal quality or does not meet criterion at all claims against the criterion do not meet expectations, has provided deficient information Score 4 3 2 1 0 3.3. The information from the assessment against the criteria will be used to identify those applications that will best meet the policy priorities of the BAPC Program. 3.4. Whilst not in a particular order, each criterion will be weighted equally. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 7

Invitation to Apply for Funding - Part B 3.5. All Applications will be assessed to ensure that they deliver value for money. The sustainability, costs, benefits and efficiency of project activity will be used by the Assessment Committee to determine value for money. 3.6. The Assessment Committee will record their preliminary assessment decision on a standardised Application Assessment Sheet. 3.7. In assessing an Application against the assessment criteria, the Assessment Committee may consider the Applicant's financial viability and the risk of the Application. 3.8. In assessing an Application the Assessment Committee may use material included in response to one assessment criterion in the assessment of other criteria. 3.9. The Assessment Committee may also seek information about any Applicant from any other source, including from within the Commonwealth, whether or not the individuals or organisations contacted are nominated as referees by the Applicant. 3.10. The Department may also consider information about the Applicant that is made available through the normal course of business of the Department. 3.11. If the assessment process identifies unintentional errors of form in an Application, the Applicant may be contacted to correct or clarify the errors, but they will not be permitted to make any material alteration or addition. Unintentional errors of form may apply to conditions of participation and mandatory / threshold criteria (if any). 3.12. Decision Maker: For the purposes of this funding round, the Minister for Health (or delegate) will be the decision maker. 3.13. The Department will provide the decision maker with a list of recommended applicants following assessment against all criteria and consideration of the Financial Viability Assessment (if required) by way of an Assessment Report. The Department s decision relating to Successful Applicants will be finalised when the decision maker indicates their acceptance of the final list of successful applicants. 4. Mandatory Requirements 4.1. Use of the word must throughout this Invitation to Apply documentation indicates a mandatory requirement. 4.2. To be clear, anywhere the word must is used in this Invitation to Apply documentation had been identified as a mandatory requirement by which the Department that, if unmet, will exclude an application from further assessment. 4.3. The following table summarises the mandatory requirements of this Invitation to Apply documentation. Document Page No. / Reference Requirement Request for Funding Proposal Page 1 You must submit provide SIX unbound copies of your Application Who Can Apply for the Funding Page 5 Applicants must demonstrate that they can foster a strong working relationship with the Department of Health and Human Services (DHHS) Who Can Apply for the Funding Page 5 Applicants must demonstrate that they have or can quickly acquire strong links with Tasmania s ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 8

Invitation to Apply for Funding - Part B existing network of palliative care providers Who Can Apply for the Funding Page 6 Applicants must be a legal entity to be eligible for funding Who Can Apply for the Funding Page 6 the lead organisation must sign the Application Form Timeframes Page 6 Funds made available under the BAPC program must be expended by 30 June 2016 Stage 1 Conditions of Participation Page 7 Each applicant must satisfy Part D, Section 1 of the Application Form Complete the Application Form Page 11 You must submit your Application for funding in the Application Form in Part D. Complete the Application Form Page 11 The Declaration in the Application Form must be signed by a person authorised to act on behalf of the Applicant. Complete the Application Form Page 11 The Application Form must be completed in English Applications from Consortia Page 11 Applicants submitting a joint Application for funding or submit on behalf of a consortium or collaboration, must include a letter of support from each additional organisation (apart from the lead Applicant) involved in the project. Complete the Application Checklist Complete the Application Checklist Complete the Application Checklist Page 12 Page 12 Page 12 Before you submit your Application, you must complete the following checklist to ensure that your Application is complete. Where an Applicant does have a Funding Agreement in place with the Commonwealth represented by the Department of Health and Ageing, details must be included in the Application under Section 2. The Declaration must be signed by an authorised officer of the Applicant. Section 1 Conditions of Participation Page 15 Applicants must satisfy all the following Conditions in order to be considered for funding under this funding round. Applicant Details Page 17 Applicants who apply for Component 1 AND Component 2 must address the Assessment Criteria for BOTH components to be considered eligible. Finance Page 28 Applicants applying for BOTH Component 1 and Component 2 MUST complete a separate Finance Budget for each Component. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 9

Invitation to Apply for Funding - Part B Finance Page 28 All amounts >$10.000 must be listed separately. Finance Page 29 All amounts >$10.000 must be listed separately. Declaration Page 31 This Declaration must be signed by an authorised representative of the Applicant. Frequently Asked Questions Page 32 A lead organisation must be a legal entity which is able to enter into the Funding Agreement. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 10

Invitation to Apply for Funding Part C PART C - HOW TO APPLY FOR FUNDING 1. Complete the Application Form 1.1. You must submit your Application for funding in the Application Form in Part D. 1.2. The Declaration in the Application Form must be signed by a person authorised to act on behalf of the Applicant. 1.3. The Application form must be completed in English. 1.4. If you are from a non-government or private sector organisation, you should include in your Application: a. one (1) copy of the organisation's Certificate of Incorporation; and b. one (1) copy of the organisation's previous financial year's financial statements (preferably audited). The Department may ask for further information about the Applicant's financial viability. 2. Applications from Consortia 2.1. Applicants submitting a joint Application for funding or submit on behalf of a consortium or collaboration, must include a letter of support from each additional organisation (apart from the lead Applicant) involved in the project. Each letter of support should include: a. an overview of how the organisation will work with the lead organisation and any other organisation(s) to support the successful completion of the project and confirmation of agreement to the lead; b. an outline of the relevant experience and/or expertise the organisation will bring to the project team; c. the roles/responsibilities the organisation will undertake, and the resources it will contribute (if any); d. details of a nominated management level contact officer; and e. details of the lead organisation. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 11

Invitation to Apply for Funding Part C 3. Complete the Application Checklist 2.1. Before you submit your Application, you must complete the following checklist to ensure that your Application is complete. Before You Begin Read this Invitation to Apply for Funding (including Part E Frequently Asked Questions and any associated Guidelines) Ensure that you understand the conditions of participation and mandatory criteria (if any) set out in Part D, Section 1 and the assessment criteria set out in Part D, Section 3 Application Form. When you submit an Application, confirm that, if your Application is successful, you will accept the terms of the Funding Agreement or specify in the application any areas where compliance is not agreed and the reasons why (see Part D Section 4 Acknowledgements ). The consequences of any inability to comply will be considered as part of the assessment process. Where an Applicant does have a Funding Agreement in place with the Commonwealth represented by the Department of Health and Ageing, details must be included in the Application under Section 2. Completing Your Application Use the template Application Form in Part D and complete every Section. Complete the Application Form in English. Indicate that the Applicant makes the acknowledgements in Part D, Section 4 of the Application Form Acknowledgements by selecting 'YES'. Include a statement declaring any actual, potential or perceived Conflicts of Interest either in the process to develop the Application, or that would exist if the Applicant were successful, in Part D Section 2. Complete and sign the Declaration in Part D, Section 5 of the Application Form (Note: The Declaration must be signed by an authorised officer of the Applicant). Submitting Your Application Check that you have completed each Section of the Application Form. For non-government Applicants: Attach to the Application one (1) copy of the Applicant's Certificate of Incorporation. Attach to the Application one (1) copy of the Applicant's previous financial year's financial statements (preferably audited). For Applicants submitting a joint/consortium Application: Ensure that the nominated lead organisation (the Applicant) is a legal entity capable of entering into a Funding Agreement with the Commonwealth. Attach to the Application a letter of support from each of the joint/consortium Applicant organisations. Ensure that each letter of support includes the information required by Clause 1.5 of this Part C. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 12

Invitation to Apply for Funding Part C 3. Submit Your Application 3.1. Submit your Application for funding in accordance with the submission details and methods on the cover page of the Invitation to Apply for Funding. 3.2. You are responsible for ensuring that your Application is completed accurately. 3.3. You may not alter the substance of your Application following its submission. If you discover an error in your Application you should inform the Department immediately in writing by email to bapc@health.gov.au. The Department may seek information from you to clarify any aspect of your Application, but it is not required to do so. 4. Retain a Copy of Your Application 4.1. It is recommended that you retain a copy of your Application for your records. 5. Taxation Implications 5.1. Applicants are responsible for ensuring they comply with the appropriate taxation legislative requirements. 5.2. For some general guidance on the taxation treatment of grants and funding from the Commonwealth, Applicants may wish to refer to the Australian Tax Office website at www.ato.gov.au. However, Applicants are advised to seek independent advice from a taxation professional on how funding paid to you (or to any entity you propose to establish to receive funding) under the Program would be treated for tax purposes. 6. Complaints Handling Process 6.1. Written complaints should be emailed to bapc@helath.gov.au. The investigation will be managed by the division responsible for managing the grants process and the Investigating officer will be senior to the person responsible for managing the process. 6.2. The Investigating officer will: Acknowledge the complaint within 10 workings days of receipt, and indicate the expected timeframe for a formal response; Ensure all correspondence on the complaint is recorded and filed appropriately; Investigate the complaint; Prepare a report; and Advise the complainant in writing of the outcome. 6.3. The response to the complainant will be in writing and will outline the issue that has been raised, what action has been taken to examine the issue and an assessment of the complaint. 6.4. If the complainant is not satisfied with the outcome, they may seek an independent internal review. 7. Independent Internal Review 7.1. The complainant should lodge a written request for further examination of the complaint and an independent review by email to bapc@health.gov.au. 7.2. The request will be referred to an independent internal review officer who will: ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 13

Invitation to Apply for Funding Part C notify the complainant of their appointment and the expected timeframe to assess the complaint; confirm the matters to be reviewed; seek any further information required to complete the review; and advise the complainant in writing of the decision within the timeframe specified. 7.3. The written notice of the decision will outline the complaint that had been raised and the matters that were taken into account in reaching the decision. 7.4. If the complainant is at any time dissatisfied with the Department s handling of a complaint, they can contact the Commonwealth Ombudsman at www.ombudsman.gov.au or 1300 362 072. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 14

Invitation to Apply for Funding Part D PART D - APPLICATION FORM FOR FUNDING UNDER THE BETTER ACCESS TO PALLIATIVE CARE IN TASMANIA PROGRAM Please submit your Application in the following form Ensure you complete ALL sections. SECTION 1 CONDITIONS OF PARTICIPATION Note: Applicants must satisfy all the following Conditions in order to be considered for funding under this funding round. Tick column 2 where you have satisfied each condition. Applications WILL NOT be further assessed if they do not meet the Conditions of Participation. Conditions of Participation Tick if criteria met 1. The Application is completed in Part D (in English). 2. The Declaration at Section 5 is signed. 3. The Applicant s legal status is as specified in Section 2 (and a certificate of incorporation is attached, if appropriate). SECTION 2 - APPLICANT DETAILS Applicant Organisational Type [Tick box against organisational type] a) Incorporated Associations (incorporated under State/Territory legislation, commonly have 'Association' or 'Incorporated' or 'Inc.' in their legal name); b) Incorporated Cooperatives (also incorporated under State/Territory legislation, commonly have "Cooperative' in their legal name); c) Companies (incorporated under the Corporations Act 2001 may be not-forprofit or for-profit proprietary company (or public companies limited by shares or by guarantee); d) Aboriginal Corporations (incorporated under the Aboriginal and Torres Strait Islander Act 2006 and administered by the Office of the Registrar of Aboriginal and Torres Strait Islander Corporations); NOTE: Attach to the Application one (1) copy of the Applicant s Certificate of Incorporation. e) Organisations established through a specific piece of Commonwealth or State/Territory legislation (many public benevolent institutions, churches, universities etc.); f) Partnerships; g) Trustees on behalf of a Trust; h) State/Territory or Local Governments; i) Where there is no suitable alternative, an individual or jointly and separately individuals. Other (please specify)... ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 15

Invitation to Apply for Funding Part D Applicant Organisational Details. DETAIL REQUIRED APPLICANT'S RESPONSE: Applicant Name [Provide the name of the legal entity submitting the Application. This will also be the name of the contracting party if the Application for funding is successful.] Australian Business Number (ABN) [If the Applicant is an entity registered on the Australian Business Register, then provide the ABN used by the Applicant.] Australian Company Number (ACN) [If the Applicant is an Australian company then provide the ACN unless the number also appears in the ABN given above.] Registered Business Name [If the Applicant uses a name registered under the business names register kept under the law of a State or Territory of Australia, then provide this name.] Registered Business Address [This needs to be the official address in respect of the legal entity submitting the Application. If the Applicant using a business name, it may be the address registered in respect of the business.] Address for Notices [This needs to be the address the Applicant primarily wishes to be used for notices to given under any contract (if different to the Registered Business Address).] Insurance Confirm willingness to obtain insurance necessary to cover the obligations of the organisation in relation to the Activity if successful. GST Is your organisation registered for GST? ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 16

Invitation to Apply for Funding Part D Authorised Contacts Preferred Contact Alternative Contact Name: Position/Title: Postal Address: Street Address: Phone Numbers (office/mobile): Fax Number: Email: Project Name Insert the name of the service and/or project: Insert Service/Project Name Brief description of the proposed service or project Insert a brief description (maximum 200 words) of the proposed service or project: Applicant's Main Functions and Activities Insert a brief description (maximum 300 words) of the Applicants main functions and activities and relevant experience and expertise that demonstrates their capacity to deliver the project: Where will your project or services be delivered? Provide details of where the project of services will be delivered. Are you applying for Component 1 or Component 2 or both (tick ONE only)? Applicants who apply for Component 1 AND Component 2 must address the Assessment Criteria for BOTH components to be considered eligible. Component 1 ONLY Component 2 ONLY Component 1 AND Component 2 ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 17

Invitation to Apply for Funding Part D Joint/Consortia Applications DETAIL REQUIRED Is this a joint Application with other organisation(s)? [Indicate Yes or No] APPLICANT'S RESPONSE NO Go to Section 3. YES Complete the rest of this Part. If YES, list the other organisation(s) (include their ABN or ACN). Confirm that you have attached to this Application a letter of support from each organisation. Conflict of interest Insert a statement declaring any actual, potential, or perceived conflict of interest either in the process to develop the Application, or that would exist if the Application is successful. Other Sources of Funding DETAIL REQUIRED APPLICANT'S RESPONSE Does the applicant (or any potential consortium partners) receive funding for the activities that are the subject of this application from any other organisation or Government department? Or has the applicant (or any potential consortium partners) applied for funding for the activities that are the subject of this application from another organisation or government department? If YES please provide the following details: Funding Source: Name; Reference (e.g. Agreement No). Description of Activity: What organisation/community needs are met? Value of funding: Period of Funding: (Start Date; End Date) Referees Referee 1 Referee 2 Name: Company Position/Title: ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 18

Invitation to Apply for Funding Part D Referee 1 Referee 2 Phone Number: Email: NOTE: Attach to the Application one (1) copy of the Applicant s previous financial year s financial statements (preferably audited). ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 19

Invitation to Apply for Funding Part D SECTION 3 FUNDING REQUEST Assessment Criteria Your response to each question within each assessment criterion is to be a maximum of 500 words. Note: Applicants are encouraged to consider Section 6 of the Program Guidelines prior to drafting a response to the Assessment Criteria. ASSESSMENT CRITERION 1: Demonstrate that the proposed service or project will meet the Objectives and Desired Outcomes of the BAPC Program. APPLICANT'S RESPONSE (500 words max.) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 20

Invitation to Apply for Funding Part D ASSESSMENT CRITERION 2: Demonstrated organisational capacity to operate the proposed services or project in the chosen region (applicants may use graphical/map based representations to assist with the identification of areas). APPLICANT'S RESPONSE (500 words max.) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 21

Invitation to Apply for Funding Part D ASSESSMENT CRITERION 3: Demonstrate how the services or project will build on or link with existing palliative care services and or programs in Tasmania. APPLICANT'S RESPONSE (500 words max.) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 22

Invitation to Apply for Funding Part D ASSESSMENT CRITERION 4: Demonstrated evidence of ability to engage with and form productive relationships with key stakeholders, including DHHS and THOs. APPLICANT'S RESPONSE (500 words max.) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 23

Invitation to Apply for Funding Part D ASSESSMENT CRITERION 5: Proposed corporate and clinical governance and operational arrangements for the proposed services or project. APPLICANT'S RESPONSE (500 words max.) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 24

Invitation to Apply for Funding Part D ASSESSMENT CRITERION 6: Demonstrate how the services or project will be delivered in accordance with best value for money practices. APPLICANT'S RESPONSE (500 words max.) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 25

Invitation to Apply for Funding Part D ASSESSMENT CRITERION 7 (For Component 2 applicants only): Evidence of how the proposed infrastructure support project will address an identified need(s) or gap(s). APPLICANT'S RESPONSE (500 words max.) ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 26

Part D PROJECT PLAN - Provide a suitable Project Plan for your proposed service or project on the template provided Output Timetable Project Outcomes Project Outcome Measure Program Outcome What key services, activities or products are you planning? When are you going to do it? What do you hope will change as a result of what you do? How will you know what has changed? Which Program Outcomes will this achieve? ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 27

Invitation to Apply for Funding Part D Finance: Applicants applying for BOTH Component 1 and Component 2 MUST complete a separate Finance Budget for each Component. Guidance for completing the Project Budget Salary costs: Provide a separate line item for each person to be employed. Include their title, award rate (if applicable) and all on-costs (workers' compensation, superannuation, leave). Project Administration costs: Provide a separate line item for each of the following (if applicable) (a) insurance (b) staff training; (c) additional costs for premises; (d) accounting and auditing; (e) stationery, printing; (f) postage; (g) telephone, internet; (h) travel; (i) vehicle running costs. Capital Expenditure: Provide a separate line item for capital items including small office assets (if any, such as mobile phones or laptop computers) that the Applicant needs to undertake the project. Total Project Funding: Indicate the total funding sought by the Applicant in this Application. Project Funding from All Sources: Indicate any contribution to cost of the project which will be made by the Applicant (i.e. premises costs, staff time, telephone costs, postage etc.). If the Applicant has applied for or been granted other funding, indicate the source and the amount of the funding awarded or applied for. Goods and Services Tax (GST): Identify the amount of GST relevant to the amount of funding the Applicant is seeking. PROJECT BUDGET (GST Exclusive) sought for this application Insert description below 2013 2014 Salaries: Please indicate no. of staff: For each staff member/s: Title; award rate Salary on-costs: (include workers' compensation, superannuation, leave) TOTAL SALARY COSTS Set-up costs NEW SERVICES: (Include costs for premises) Project Administration: (include stationary/printing; postage; telephone/internet; vehicle running costs; reporting costs; staff training costs. All amounts >$10,000 must be listed separately) Insurance: (include the types and amounts of insurance $ GST Excl. 2014 2015 $ GST Excl. 2015 2016 $ GST Excl. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 28

Invitation to Apply for Funding Part D necessary to cover all obligations in relation to this activity) Project travel: Resources (literature etc.): Accounting / Audit fees: Other: (All amounts >$10,000 must be listed separately) CAPITAL EXPENDITURE: TOTAL PROJECT COST (GST EXC): 10% GST TOTAL PROJECT COST GST INC: Project Funding from all Sources If you will receive any other funding to support this project (State/local government, donations etc.) please complete the table below. Insert description below 2013 2014 $ GST Excl. 2014 2015 $ GST Excl. 2015 2016 $ GST Excl. Better Access to Palliative Care in Tasmania Program contribution: This figure should match the total project cost (gst exc) from the table above This figure should match the total project cost (gst exc) from the table above e This figure should match the total project cost (gst exc) from the table above e Income from other sources: Please identify sources: TOTAL GST EXC: ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 29

Invitation to Apply for Funding Part D SECTION 4 - ACKNOWLEDGEMENTS If this Application for funding is successful, the Applicant acknowledges and agrees: that the project name, brief project description, the amount of the funding and name of the Applicant's organisation may be: included in the Department s reporting on the internet in line with the Commonwealth Grant Guidelines and Senate Orders; used by the Commonwealth in media releases and other publications (such as Annual Reports); and/or used to compile a consolidated report. that it will be required to provide proof that it has sufficient insurance cover to conduct the proposed activities specified in this Application Form if requested; and that the funding will be provided in accordance with the terms of the Funding Agreement at Attachment B and the Applicant agrees to abide by the terms of that Agreement. [Please circle to indicate whether the Applicant makes the above acknowledgements] If NO, please explain why the Applicant has not made the above acknowledgements............. Please list any Agreement clauses where there is a level of non-compliance in the table below. YES / NO Clause Reference Non (N) or Partial (P) Compliance Reason for Non Compliance ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 30

Invitation to Apply for Funding Part D SECTION 5 - DECLARATION Guidance for completing this Declaration This Declaration must be signed by an authorised representative of the Applicant (or, if this Application is a joint/consortia Application, an authorised representative of the Lead Organisation). The authorised representative should be a person who is legally empowered to enter into contracts and commitments on behalf of the Applicant / Lead Organisation. An Application which does not provide all required information or which contains false or misleading information may be excluded from consideration. I hereby apply for a grant under the Better Access to Palliative Care in Tasmania of $...[insert GST inclusive amount] for...[insert Project title]. I certify that the information given in this Application is complete and correct. Signature: Name (BLOCK LETTERS): Position of Applicant: Date: ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 31

Invitation to Apply for Funding Part E PART E - FREQUENTLY ASKED QUESTIONS Will late Applications be accepted? The Department will only accept your Application if it is late as a direct result of mishandling by the Department. In all other circumstances, in the interests of fairness, the Department reserves the right not to accept late Applications. In considering whether it would be fair to accept a late Application, the Department will take into account the degree of lateness, whether the cause of the lateness was beyond the Applicant's control and such other facts as it considers relevant. The Department may also ask the Applicant to provide evidence to support its claims regarding the reasons for late submittal. When will my organisation find out if my Application has been successful? The selection process may take some time to complete, but it is anticipated that Applicants will be notified of the outcome by the 30 June 2013. Can a number of organisations submit a joint Application? Yes. If the work or project benefits or involves more than one organisation, you can submit a joint Application. However, in order to manage the funds appropriately, if a joint Application is successful, the Department will enter into a Funding Agreement with the nominated lead organisation. Additionally, the joint Application should include a letter of support in line with Part C, Clause 2.1. What is a lead organisation? If you submit a joint Application with one or more other organisations, nominate a lead organisation for the Application. The lead organisation for the project will, if your Application is successful, sign the Funding Agreement, receive the funding and assume legal responsibility for performing the Funding Agreement. A lead organisation must be a legal entity which is able to enter into the Funding Agreement. Are there any GST or income tax-related issues involved in receiving funding? Yes. Clause 3.9 of the Standard Funding Agreement outlines the taxes (including GST), duties and government charges for which successful funding Applicants will be responsible. We recommend that you seek independent advice regarding the income tax implications of receiving funding. When will my organisation receive the funding? If your Application for funding is successful, an initial payment may be made after the Funding Agreement has been signed by your organisation and by the Department representing the Commonwealth. All other payments of the funding will be based on deliverables (i.e. progress reports) as set out in the Funding Agreement. Who should I contact if I need more information? If you have any other questions or you need more information, you can contact the Contact Officer identified on the cover page of this Invitation to Apply for Funding. Please ensure that you allow sufficient time for the Contact Officer to answer your query and for your organisation to complete its Application before the closing date. ITA: Better Access to Palliative Care in Tasmania, ITA No. DoHA/273/1213 32