Practice Partners Program

Application Form

Applications close 5pmWednesday, 2 November 2016.

Please send to Souzi Markos at

(subject line: Practice Partners Application)

Organisation details
Project title
Name of organisation
Postal address
Contact person
Email address
Work phone

Please answer each of the following questions. Please keep to the specified word limit.

  1. Provide a brief summary of what the project will do. (100 words)
  1. Which stream(s) are you applying for:

☐Consumer participation☐Person centred care

  1. Explain the project’s aims and objectives in relation to your chosen stream. (200 words)

/ Level 8
255 Bourke Street
MELBOURNE VIC 3000 / Phone: (03) 9664 9343
Fax: (03) 9663 7955

ABN: 96 599 565 577


  1. Clearly describe how your project will address the key selection criteria with specific attention to the involvement of consumers in your project.

(300 words)

Involvement of consumers in project design and governance
New, innovative
Scalable and replicable
Commitment to sharing the project steps and outcomes with other services
Small, rural and regional services (if applicable)
Involvement of less-represented groups or communities
  1. How does the project fit within your organisation’s strategic plan?

(100 words)

  1. What is your strategy for the sustainability of this work after HIC’s funding? (200 words)
  1. Provide details of your implementation strategy including:(250 words)
  • how your organisation will undertake the project
  • how consumers (patients & families) will be involved in the project (timing, estimated number and responsibilities)
  • who will oversee the project
  • timelines
  • breakdown of project stages


  1. Budget:

Item / Amount
Total cash funding requested in this application.
Please indicate an estimate of how funds will be spent: / $
Total hours of HIC staff time requested as in-kind support.
Please estimate below the type and timing of input: / $
Contribution (cash and/or in-kind) from your health service for the project / $
Total budget (cash and in-kind from HIC) for the project / $
  1. Are there other sources of funding being sought or secured from your organisation or externally for this project?

☐Yes ☐No

If yes, please complete below:

Organisation / Amount / Cash or In-kind? / Secured?
☐Cash ☐In-kind / ☐Yes ☐No
☐Cash ☐In-kind / ☐Yes ☐No
☐Cash ☐In-kind / ☐Yes ☐No
  1. Who will be impacted by this project and how will you measure this and other outcomes? (200 words)
  1. Please provide two external referees who are able to speak about the project and your organisation.

First referee
Second referee
  1. Endorsement

This application form must be signed by your organisation’s CEO.

Signature of CEO

For more information

Please contact Souzi Markos at (03) 9664 9343 or