Community Road Safety

Application form

Contract EW12/01 – Road Safety Programmes 2012-2015

Applicant details

Date:

District/City:

Organisation:

Contact person’s name:

Address:

Telephone (H): (W): Fax:

Mobile: Email:

Project Coordinator signature:

Road Safety Coordinator signature:

Attach information about your organisation including the latest annual financial report.

  1. Project title:
  2. Goal:
  3. Your objectives (expected outcomes):
  1. Describe how your proposal/project would contribute to one or more of the Gisborne District’s community outcomes:
  1. Describe how your proposal/project would result in achievable outcomes aligned with Safer Journeys and Communities at Risk register:

  1. Problem definition/risk factors:

Please tick below the theme(s) that best describe the focus of your activity:

Community Road Safety themes

High Concern

alcohol/drug impaired driving

rural road safety

intersection crashes (rural and urban)

Medium Concern

motorcyclists

safe walking and cycling

improving the safety of young drivers

addressing driver distraction and inattention

reducing the impact of high risk drivers

speed

Low Concern

unrestrained drivers and passengers

heavy vehicles

reducing the impact of fatigue

  1. Please briefly describe the proposed activity and planned intervention:
  1. Intervention/actions planned:

  1. Expected outcomes:
  1. How will the community be involved:
  1. Number of sessions (where applicable):
  2. Expected number of participants per session:

13.Explain why the programme/community development initiative is needed in your community:

14.Which road safety partners will be involved and what will they do?

15.Describe links with Safer Journeys and Communities at Risk register:

Project management

16.How will you know if the objectives have been met?

17.How will you measure this in terms of impact, success, progress and achievement?

18.What is the expected timeframe?

  1. How will you manage health and safety for any events and activities?

Proposed budget

  1. Outline of expenditure (in category areas, eg. Venue hire, publications)

Project budget / $
Contribution from partners: Gisborne District Council (GDC) 68%
Contribution from partners: Provider 32%

21.Are you also applying elsewhere for this initiative?

Yes

No

If yes, please identify below and provide confirmation letter from agency who will be contributing the 32% funding:

Website Links to Related Documents

Closing Date for Applications

Applications will close at the Gisborne District Council’s Administrative Office, Fitzherbert Street (PO Box 747), Gisborne at 1pm on Wednesday 22 February2012.

Applications are to be enclosed in a sealed envelope addressed to:

The Tender Box

Gisborne District Council

PO Box 747

Gisborne 4040

The envelope (and courier pack, if applicable) shall be marked in the top left hand corner:

“Application for Contract EW12/01 : Road Safety Programmes 2012-2015”.

Any queries in relation to these documents shall to be directed to Lenora McDonald, Road Safety Coordinator, Gisborne District Council, Ph. (06) 867 2049.

Roading: n-231748 – Updated January 2012

Fitzherbert StreetPO Box 747, Gisborne 4040 •PHONE: (06) 867 2049 •FREEPHONE:0800 653 800•FAX(06) 867 8076

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