This Form Should Be Submitted Together with Applications for Projects That Include The

Agency Participation Form

This form should be submitted together with applications for projects that include the participation of sites or programs that receive funding from the Victorian Responsible Gambling Foundation.

Project Title

Organisation / Institution

Project Sites / Locations

Which of the following Victorian Responsible Gambling Foundation funded programs or sites will the project involve or impact?
Gambler’s Help
Gambler’s Help Line
Gambling Help Online
Centre for Culture, Ethnicity and Health (CEH)
Victorian Aboriginal Health Service (VAHS)
Victorian Aboriginal Community Services Association Ltd (VACSAL)
Primary Care Partnership
Victorian Responsible Gambling Foundation
Websites owned by the foundation
Other (specify below)

List all agencies and/or program sites that will be involved or impacted by the research:

Have you already made contact with any of these agencies?

YesNo

If yes, please list your contact(s) below:

Name / Title

Participants

Do you intend to recruit participants through an agency funded by the Victorian Responsible Gambling Foundation?

YesNo→ Go to “Data”

Describe your request, including the number of participants required and the time required for their participation:

Describe your proposed recruiting strategy:

Attach a copy of your plain language statement and consent form. Also attach a copy of your survey, focus group or interview questions or any other instrument you intend to use as part of the project.

Data

Are you seeking access to data held by the Victorian Responsible Gambling Foundation?

YesNo→ Go to “Other”

Are you seeking:

Aggregate summary or statistical information

De-identified individual records (where the individual’s identity is not apparent and cannot be reasonably ascertained by the researcher or others)

Identifying or potentially re-identifiable data (where the individual’s identity is apparent, or could reasonably be ascertained by the researcher or others, i.e. through data linkage/matching)

Describe your request:

Other requests

Do you have another request for the Victorian Responsible Gambling Foundation?

YesNo

If so, describe your request:

Agency Participation Form1