Request for Proposalfor: After Hours Primary Care Innovation Grants

Request for Proposalfor: After Hours Primary Care Innovation Grants

Respondent’s Information
Name of Service Provider/Organisation:
Address of registered office:
Place of registration:
Australian Business Number:
Principal office (if different to the above):
Telephone:
Email:
Name and title of Respondent’s authorised agent:

I accept the provisions contained in the Conditions of this Request for Proposal.

Signature Respondent’s authorised agent PRINT NAME and DATE

Please indicate whether this Proposal is seeking funding from the

☐Service Delivery Stream (funding not to exceed $100,000 ex GST)
☐Service Development Stream (funding not to exceed $50,000 ex GST)

Assessment criteria
1.1Describe the nature and extent of your organisation’sprevious and current experience in delivering similar goods and/or services. (Weighting 30%)
1.2Clearly articulate the demonstrated need for funding under this Innovation Grants round. (Weighting 25%)
1.3 Describe your organisation’s willingness, capability and/or proposed strategies to deliver the goods and/or services required. (Weighting 25%)
1.4 Budget that is fit for purpose and provides a clear justification for required funding. (Weighting 20%)
Budget line item / Value ($ ex GST) / GST / Value ( $ inc GST)
Staffing (including on costs)
Service delivery costs
Administration costs (must not exceed 6% of the total budget)
Other (please specify)
TOTAL
Please add additional lines as required
Compliance Criteria
Conflict of Interest: Provide details of any interests, relationships or clients which may or do give rise to a conflict of interest and the area of expertise in which that conflict or potential conflict does or may arise, plus details of any strategy(ies) for preventing and/or managing conflicts of interest (actual or perceived).
Risk management strategies: Provide details of all risk management strategies and practices of the Applicant that would be applicable or relevant in the context of the supply of Goods and/or Services.
Accreditation/Registration/Certification: Provide relevant details as appropriate.
Accreditation/Registration/Certification:
Accreditation/Registration/Certification Body:
Standard/Obligation:
Accreditation/Registration/Certification:
Accreditation/Registration/Certification Body:
Standard/Obligation:
Schedule of Insurance information: ACT PHN requires appropriate insurance provisions for the supply of Goods and/or Services contemplated under this Invitation (e.g. public, product, professional liability). Provide details of all relevant insurances maintained by the Applicant. (Note: ACT PHN may seek confirmation of such Insurances through the provision of certificates of currency).
Name of insurance company:
Policy type (e.g. public liability, professional indemnity, etc.):
Policy number(s):
Expiry dates:
Limit of liability:
Relevant exclusions:
Name of insurance company:
Policy type (e.g. public liability, professional indemnity, etc.):
Policy number(s):
Expiry dates:
Limit of liability:
Relevant exclusions:

Please remember to pdf your response prior to submitting to

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