Clinic Extension Grant Application2014

PapScreen Victoria

Clinic Extension Grant Application2014

Applications close on: Friday 9 May 2014

Before completing this application form, ensure you have read the

PapScreen Victoria Clinic Extension Grant Guidelines 2014 located at

1. Organisation details

Organisation:
Postal address:
Suburb:
Postcode:
Telephone (BH):
Email:
Department of Health region:
Barwon South WestHume
Eastern MetroLoddon Mallee
GippslandNorth West Metro
GrampiansSouthern Metro
Local Government Area:
For further information regarding which LGAs are applicable for a grantseePapScreen Victoria Clinic Extension Grant Guidelines 2014
Amount of funding requested from PapScreen Victoria? $ (Max $2,500.00 inc GST)

2. Person responsible for managing the project

Contact name:
Position:
Telephone (BH):
Email:

3. Person responsible for grant money

Contact name:
Position:
Telephone (BH):
Email:

4. Have you applied for a PapScreen Victoria grant previously?

Yes

No

5. If yes, was your organisation successful?

Yes

No

6. Clinic information

If successful, do you intend to:

Extend clinics (for cervical screening providers working in general practice, community health or outpatient services to offer free cervical screening clinics)

Support an outreach program (for existing cervical screening clinics to run free outreach services in the community)

Required target group:

underscreened women aged between 25to 70 years, who have not had a Pap test for four (4) or more years; and reside in a Local Government Area with a cervical screening participation rate (for the period 2011-2012) below the Victorian state average, 60.0%.

With a specific focus on the following target groups (optional):

Women of low socio economic status

Aboriginal and Torres Strait Island (ATSI) women

Culturally and Linguistically Diverse (CALD) women

Older women

Younger women

Women with disabilities

Lesbians

If ‘other’ please describe

How many clinics will be conducted?

How regular will the clinics be? (eg one per week / month)

(PapScreen recommend allowing a minimum of 30 minutes per appointment to enable a preventative women’s health check)

Approx. cost per clinic*

Who will be performing the Pap test? (eg nurse cervical screening provider, GP)

Number of underscreened (4+ years) women who potentially can be reached through the Clinic Extension Grant

How did you obtain this number?

(If possible, please attach report to this application)

Medical Software

Clinical Audit Tool

VCSSix-monthly Statistical Summary/ Provider Report

PapScreen Statistical worksheet

Other ______

* All clinics must be provided free of charge

7. Advertising and promotional information

How do you intend to promote your extra clinics or outreach activity?

Newspaper advert

Newspaper editorial

Website

Radio

Flyer

Poster

Invitation letter

Newsletter

Other

If ‘other’ please describe:

8. Budget

Please provide a breakdown of your estimated total costs, including any financial or in-kind contributions from your organisation.

NB:

• Due to limited funds, agencies that demonstrate a financial or in-kind commitment, for example administration support, salary costs etc will be looked upon favourably.
• The following will not be funded:

-Establishment of new or ongoing Pap test clinical services

-Training of community or women’s health nurses to become cervical screening providers

-Capital items such as computers or other office equipment, mobile phones and clinic equipment

-Resource development costs where a similar resource is/has already been developed by PapScreen Victoria or Cancer Council Victoria

Costs to cover /

Details

/

Agency to fund $ or in-kind

/ Funding sought from PapScreen Victoria
Advertising and promotion / $ / $
Nurse salary / $ / $
Venue / $ / $
Transport
(for outreach clinics only) / $ / $
Administration / $ / $
Other / $ / $
Total amount requested from PapScreen Victoria / $

9. Agreement

Name of applicant:
Date:

In submitting this application form, I agree that I understand and will follow the conditions of funding as outlined in this document and the PapScreen Victoria Clinic Extension Grants Guidelines 2014 if I am successful in obtaining a grant.

I agree to be a cervical screening advocate for PapScreen Victoria and feature in media releases and relevant communications strategies (optional).

Yes No

Hard copies of applications will notbe accepted – all applications to be filled in electronically and returned via email

For any assistance please contact:

Kirsten Hausknecht

Community Health Professionals Coordinator

T: 03 9514 6425

E:

PapScreen Victoria Grant application 2014 - 1 -