Habitat Protection FundApplication Form 2018 Round 1
Before you applyBefore you start filling out this form read theHabitat Protection Fund Application Guideto help you decide whether you are eligible to apply to the Habitat Protect Fund (HPF).
If you have any questions about your application contact WWF on0800 435 7993 or 04 471 4297.
You must complete all sections of the form.
Once you have completed your application
Applications forms must be saved in Microsoft Word document format, any other format will not be accepted.
Applications must be emailed to
Please check all supporting information is attached.
Completed application forms and supporting information must be received by 5pm on the closing date.
You will receive an automated response acknowledging receipt of your application by email.
You will be notified of the outcome of your application within two months of the closing date.
Section 1: About your organisation
1. Contact Details
Contact name
Role in organisation/project
Postal address
Include post code
Website(if applicable)
Facebook(if applicable)
Phone number
Landline and mobile / and
2. Organisational Details
Organisation/group name
Legal status of organisation
Provide evidence of IRD charitable status with supporting information if applicable / Incorporated society Charitable Trust
Maori Trust Board Other
please specify
The following financial controls should be in place
Please confirm if the following exist:
Do you have a bank account?
Yes No
Two signatories to bank accounts
Yes No
Appointment of a treasurer who is responsible for keeping the financial records
Yes No
Regular financial reporting to every full meeting of committee or board of trustees
Yes No
Section 2: About your project
- Project Details
Project name
Location of project
Region (e.g. Northland
Local Authority
Outline the project and its outcomes
Provide a summary of what is being proposed, what to achieve and why.
Do you have a strategic plan?
Yes No If no, what plans do you have to produce one?
Do you have an operational plan that identifies project milestones, timelines and resources required?
Yes No If no, what plans do you have to produce one?
You do not need to send these to us at this stage but will need to be able to provide a copy if requested
.
Briefly list the technical expertise you have available to the group
Complete the table
Name / Technical expertise
25. Project Monitoring
List the outputs that will result from WWF’s contribution
e.g. The production of a detailed management plan for x reserve, possum control in xha, x m riparian fencing, x traps installed
How will you measure the success of your project?
Describe how you will monitor your projectoutcomes what indicator(s) will you use
You can use the HPF Monitoring Toolkit as a guide.
Complete the table
Outcome
Tangible results your project is trying to receive. / Indicator
What you will measure
e.g. possumabundance, bird
abundance, birddistribution,
water quality aquaticinvertebrates / Measure
How you will measure e.g. five minute bird counts, tracking tunnels, RTC
32. Project Priorities
Please identifythe HPF prioritiestheproject meets. As outlined in theHabitat Protection Fund Application Guide
Projects in areas close to population centres with the objective of increasing awareness of
biodiversity conservation and increasing community involvement in conservation action
AND/OR
Projects working in areas of lowland biodiversity including
Freshwater environments and catchments Coastal and dune systems
Wetlands and estuarine systems Threatened indigenous species habitat
Lowland and coastal forest and scrub communities
AND/OR
Projects in areas where there are remaining patches of high quality habitat which are threatened by habitat fragmentation, changes in land use or invasive species
Does your project meet local conservation priorities identified by DOC Conservation Management Strategy or Council biodiversity action plans or strategies?
Yes No
If so please say how?
4. Project Budget
Amount requested from WWF
GST Exclusive
Funding is allocated for one year.
Maximum allocation is $15,000.00
Have you received funding from WWF before?
If yes, when, from which Fund and how much? / Yes No
What activities do you intend to use the funding for (Exclusive of GST)?
Complete the table. For eligible costs and activities refer to HPF Guidelines page 6
Activity
e.g. Pest animal control revegetation, monitoring, surveys
administration, coordinator time / Briefly describe
e.g. number ofbait stations, traps, or plants to be purchased
hours for contractors and staff / Cost
Total Cost
- 56. Other Funding
Have you secured other funding, for this project?
Yes No
If yescomplete the table below
Please note that volunteer time, in-kind donations of tools, equipment, publicity etc. can be counted as matched funding. To calculate the value of volunteer time, multiply the number of volunteer hours estimated by $25/hour
Source of funding / Funding secured ($)
Total secured
If you do not secure the level of funding you require from WWF or other funders explain how you will meet the shortfall?
What measures have been taken to ensure the project becomes financially viable over the long term?
67. Community Support, Partnership and Collaboration
Describe community support for the project and how you intend to involve the community further
Describe how your group involves tangata whenua, and honours the principles of partnership under the Treaty of Waitangi, in the design and delivery of this project
What input, have you had from local iwi or hapu representatives in designing this project?
List the names of organisations/groups providing support to the project or that you are collaborating with (e.g. council landcare agency, DOC, other restoration groups) in the table. It may help your application to provide letters of support from these organisations/groups
Name of organisation / Details of support and/or partnership
E.g. technical support, funding, advice etc.
78. Health and Safety
IMPORTANT INFORMATION:
Please read this section carefully and complete it in full.
If you do not provide the required information and/or your health and safety documentation is not acceptable we may not be able to consider your application.
Are you aware of your responsibilities under the Health and Safety at Work Act 2015? / Yes No
Has your organisation received any notices, warnings or prosecutions under the Health and Safety at Work Act 2015 or previous health and safety legislation?
If yes, please provide details: / Yes No
Who will be responsible for coordinating health and safety for the project in this application?
Has your organisation been involved in any accidents or incidents resulting in environmental damage or pollution? If yes, please provide details: / Yes No
PCBU: Person Conducting Business or Undertaking
A PCBU is usually a person or an organisation that is carrying out a business, and has the primary responsibility under the HSWA.
A volunteer association, which is a group of volunteers working together for a community purpose (and that does not employ anyone) is not considered to be a PCBU.
Please contact us if you are unsure as to whether you are a PCBU.
If your organisation is a PCBU* you mustsubmit your health and safety policy.
Non-PCBUs are not required to submit an organisational H&S policy, however, it will help us process your application if you do submit one.
See application guidelines for more detail of the information required. / included
Yourorganisation's health and safety policy must include provisions for the following:
- a work environment free from risks to health and safety
- safe equipment, structures and systems of work
- safe use, handling, and storage of plant (including vehicles and tools), substances and structures
- relevant information, training, instruction, induction, supervision and monitoring
- emergency procedures protocols for all workplaces and activities
- risk identification and management plans for all workplaces and activities
- incident reporting, investigation and response procedures
- ongoing monitoring and review process for health and safety systems, worker health and workplace exposures
- policies and procedures for managing contractorsto ensurethey meet legal health and safety obligations
All applicants must provide evidence of project specific health and safety planning for the activities for which you request funding
See application guidelines for more detail of the information required / included
Your project specific health and safety plan must include provision for the following:
Only include information applicable to the work you will be carrying out using Habitat Protection funding if your application is successful.
Please read Application Guidelines carefully for more detail about the kind of information required here.
- Identifying and managing risks associated with this project
- Ensuring participants are appropriately qualified, competent and informed to carry out the activities safely
- emergency procedures and protocols
- incident reporting, investigation and response procedures
If you intend to use the HPF grant to fund high risk activities, you also need to provide the following information for those activities:
Refer to Appendix 2 for a list of activities that WWF consider to be high risk. WWF-New Zealand reserves the right to amend this list at any time.
- Job Safety Analysis (See Appendix 3 for a template)
- identification of who will be conducting the high risk activities, assessment of their skills, competence, and any required qualifications and certification
If contracting out any activities funded by HPF you will need to submit the contractor’s health and safety policy and project specific planning for those activities / included
HEALTH AND SAFETY NOTES:
Agrichemicals
To find out if you need approved handler certification for the substance you will be using visit the Worksafe new Zealand website and
Agrichemical users have a responsibility to demonstrate that they understand their obligations and best practice for the use of agrichemical products. The GROWSAFE certificate issued after completion of a GROWSAFE course provides credible evidence that you have the skills and knowledge to use agrichemicals correctly.
More information
For more guidance on your health and safety obligations visit
810. Land Information
Who owns the land?
DOC Maori Land
Regional Council District council
Private Other
Please give name of landowner: If other please specify:
If the applicant does NOT own the land or property in the application, do you have an agreement for the use of the land for the project from the owner
Yes No
Please give details of current protection status of the land your project is working on
Public conservation land Unallocated Crown land
Council Reserve Regional Park
QEII Covenant Nga Whenua Rahui
Private land no protection Other
please specify
If not protected are there plans to increase protection in the near future e.g. by QEII Covenant?
Yes No
If so what?
911. Permissions, Consents and Licences
In addition to landowner permission do you require any permissions, consents or licences to complete the project (e.g., resource management)
Yes No
If yes,what permission is required, and when is a decision expected (if known)?
102.Staff
Do you employ staff? / Yes No
If yes, how many full time equivalents?
HPF grants are for community groups employing less than five staff (full time equivalent)
Supporting Information (see below)
I have included the required supporting information as outlined in the Habitat Protection Fund Application Guide
Privacy Act
Any personal information about individuals you provide in this application will be used only to assist with the administration and assessment of your application and in publishing the results of approved grants.
The group and personal information collected will be exclusively for the use of WWF New Zealand’s Board and staff, the Tindall Foundation and any other parties contracted by WWF New Zealand to act on behalf of WWF New Zealand. Groups and individuals have the right to check and correct any personal information held by WWF New Zealand.
PLEASE NOTE We may contact you and you may be asked to provide additional information to help us assess your application.
Supporting Information
Please check you have provided
Evidence of IRD charitable status
Details of any consents, permits or licences needed for the project
Evidence that the project has support from the Department of Conservation and/or local authority (for example a letter of support)
Details about consultation with the local hapu and/or iwi about the project, and letters of support where appropriate
Relevant health and safety documentation as requested in section 8
An agreement for the use of the land for the project from the owner
DeclarationI declare that the statements made in this application are true and that the information provided is correct
Signed:
Print name:
Position held in organisation:
Date:
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Appendix 1: Common Hazards/Risks for typical restoration projects
Project Name: ______
Date risk register updated: ______
Assessed by: ______
Risk I.D. / Activity / Hazards / Maximum Credible Impact (likely outcome of an incident) / Risk Assessment without Controls / Risk Controls / Current Risk Assessment(Residual Risk) / Comments
Consequence (C) / Likelihood (L) / Risk Ranking (C x L) / Consequence (C) / Likelihood (L) / Risk Ranking (C x L)
1 / Working Near Water /
- Stagnant water infections to exposed cuts/mosquito or other insect bits
- Drowning
- Current – being swept away
- Trapped due to snags from trees and other debris
- Sudden change in water levels
- Induct all personnel to site and identify site specific hazard associated with working around water
- Provide insect repellent
- Appropriate clothing – long sleeves, and trousers, or waders
- Have first aid kits on site – clean all cuts and cover
- Wear life jackets or similar when working on or in the water
- Complete a risk review to determine strength of current – use of safety line, working downstream of snags.
- Check weather forecast before and during working in or near waterways
- Implement an emergency response plan
2 / Working near fences /
- Electric fence/electrocution
- Barbed wire cuts/laceration
- Trips or falls
- Use gates or stiles where possible instead of climbing fences
- Climb fences close as possible to a fence post
- Ask land owner to switch off electric fences if possible
3 / Fauna and Flora /
- Insect or animal bites or stings
- Being crushed or struck by animals/livestock
- Allergies/anaphylactic shock
- Cuts from barbs or branches
- Trips and falls
- Complete an induction – identify any personnel that may require assistance if stung or suffer allergic reaction
- Use insect repellent
- Ask land owner to move livestock from work area
- Carry first aid kits and other first aid items if required (Inhalers, Epi pens)
- Have first aid kits on site – clean all cuts and cover
- Use designated paths or walkways
4 / Use of hand tools (Shovels, pruning saws, machetes.) /
- Cuts, blisters and scraps
- Sprains or strains
- Induction on safe use of tool or equipment
- Use of appropriate PPE (Gloves, boots or covered shoes)
- Stretch and warm up before use of tools and equipment
- Rest, hydrate and eat regularly
5 / Accessing site in varied topography /
- Ground conditions- slips trips and falls
- Site accessibility – require 4wd, hilly, embankments or bluffs
- Get a briefing on area where work in to be undertaken
- Use appropriate vehicle to access site (Do you need a 4WD?)
- Wear appropriate footwear
- Check weather forecast before going to site, will it have an impact on site access?
6 / Working alone /
- Injured and unable to communicate
- Loose bearings/lost
- Vehicle or other transport breaks down
- Complete a risk assessment – Is it safe to work alone
- Implement a communication plan – Is there cell phone coverage if not how will you maintain communications
- Implement an emergency management plan
- Confirm planned route to site
7 / Driving /
- Use of incorrect vehicle to access site
- Other drivers on the road
- Weather/environmental
- Fatigue/hours worked
- Unskilled drivers/operators
- Time of day (early morning/driving at night)
- Distractions
- Use appropriate vehicle to access site
- Complete any driver training if required (4WD)
- Review the weather forecast - Will the weather have any impact on site access (fording rivers etc.)
- Share driving activities to reduce fatigue
- Remain vigilante of other road users, obey the road rule
- Use hand free sets for cell phone use or pull over when using a cell phone while driving
8 / Working outdoors /
- Exposed to the elements – Sun, rain, ice, snow
- Changing weather – sudden rise in water levels, decreased visibility
- Wear appropriate clothes for the task being completed – long sleeves, trousers, sun hat
- Use sun block
- Rehydrate and eat regularly
- Plan for the weather conditions you are likely to encounter – review weather forecast
9 / Landowner or occupier engagement /
- Aggressive behaviours
- Not provided site access/have to use alternate route resulting in changes to work methodology
- Notify land owner in advance of going to site
- Notify and liaise with any third parties (Iwi groups) prior to going to site
- Confirm site access and comply with land owners requirements around livestock etc
- If you discover any site being used for illegal activities do not touch anything, leave the area and report to the Police
10 / Operating plant and machinery /
- Personnel injury or injury to third party
- Collision or roll over resulting in damage to plant or property
- Damage to the environment (Spill, fire)
- Trained or competent operator only to operate plant or machinery
- Supervision by a competent operator to be provided if any operators of plant and machinery are undergoing training
- Inspect all plant and machinery before use to ensure it is fit for purpose
- Only use plant and machinery for the purpose it was designed
- Ensure all licences are current where a licence to operate is required
- Report all incidents or damage to plant and machinery
11 / Operating power tools /
- Personnel injury or injury to third party
- Tool or equipment malfunction
- Damage to the environment (Spill, fire)
- Trained or competent operator only to operate power tools
- Supervision by a competent operator to be provided if any power tools and are undergoing training
- Inspect all tools before use to ensure it is fit for purpose
- Only use tools for the purpose it was designed
- Report all incidents or damage to tools and equipment
12 / Manual Handling /
- Personnel injury -Sprains, strains, slip, trips and falls – Placing fish nets into waterways, slippery under foot conditions, lifting heavy loads
- Warm up before carrying out any manual handling tasks
- Can the task be completed using a machine or a specific tool
- Only lift items that are within your safe lifting capabilities
- Report any sprains, strains or niggles
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