Smokefree Community Partnershipgrant
Introduction

The Health Promotion Agency’s (HPA’s) mission is to inspire all New Zealanders to lead healthier lives. To help achieve this HPA’s tobacco control team works alongside other organisations to achieve the Government’s goal of Smokefree 2025. A key component of tobacco control work is to promote smokefree healthy lifestyles.

Every year a significant number of children are exposed to second-hand smoke in their homes, cars, and other environments like sports grounds and playgrounds. The 2013 Census highlighted that more than 600,000 children are living in a home with at least one smoker[1]and it is estimated that over 100,000 children are exposed to second-hand smoke in vehicles within a typical week[2].

What is the purpose of the Smokefree Community Grant?

The purpose of the Smokefree Community Partnership Grantis to support community groups to develop and implement initiatives that promote nationally consistent messages, using an approach that is locally appropriate. This funding is intended to enable initiatives that otherwise may not be possible.

Priority Populations

Māori, Pacific, and pregnant/hapu women and families and whānau with young children.

Pre-assessment criteria

To be eligible to apply for the funding, you must be able to answer ‘yes’ to each of these pre-conditions.

  1. Clearly identifies one of the target audiences as Māori, Pacific, and pregnant/hapu women and families and whānau with young children.
  2. The application isnot requesting financing costs associated with running an organisation, such as staff and equipment costs.
  3. The application is from an eligible organisation. (ie Not individuals, early childhood centres, schools, polytechnics, universities, adult education and alternative education facilities, public sector organisations)
  4. The organisation is not affiliated to the tobacco, alcohol or food industries.
  5. The proposed project does not duplicate services already available in the community.
  6. The funding applied for is not retrospective.
  7. The proposed project is not currently receiving funding from HPA.
  8. The proposed project does not require ongoing funding from HPA.
Application criteria

Applications that meet the above pre-assessment conditions will be put forward to the evaluation panel. Factors taken into account when evaluating applications will include the following weighted criteria:

Assessment Criterion / Weighting
1. / Clearly explains how the project will work with one of the priority populations ie, Māori, Pacific, and pregnant/hapu women and families and whānau with young children. / 25
2. / Clearly demonstrates how the project will encourage families and whānau to create smokefree environments. / 20
3. / The proposed project has clearly defined goals and objectives. / 20
4. / Demonstrates partnerships or linkages within the community. / 15
5. / Demonstrates cost-effectiveness with a clear budget breakdown. / 5
6. / Demonstrates innovation (does not duplicate existing services within the community). / 5
7. / Provides some evidence of considering other healthy lifestyles eg. being sun safe, healthy eating, and/or minimising harm from alcohol and gambling. / 5
8. / Includes a plan for evaluating/measuring the success of the event. / 5
Total / 100
What funding is available?

Providers may be eligible for up to $5,000 (excluding GST).

If an application is successful we can pay up to 75% of the funding upfront (after the letter of grant is signed) and the remaining25% (after the final evaluationreport has been completed).

Key dates
Application process opens / Wednesday 21 September 2016
Closing date for questions / 12 Noon Friday 7 October 2016
Date HPA staff will respond to questions by / 5pm Wednesday12 October 2016
Closing date for applications / 12 Noon Thursday 20 October 2016
Applicants notified of outcome / 17 – 18 November 2016
Letter of Conditional Grant signed / 21 – 23 November 2016
Commencement Date for projects / Thursday 24 November 2016
Community project completion date / Friday 28April 2017
Final evaluation report (project snapshot) and final tax invoice due to HPA / Wednesday 31 May 2017
Obligation to return grant funding

If your entity receives funding by way of a conditional grant, and your entity does not fulfill the terms under which the grant is made as set out in the Letter of Grant, you may be required to refund to HPA part or all of the funding. This is clearly set out in the funding letter.

How do you apply for funding

Please complete the following tasks before submitting your application.

  • Read through the informationincluded in the application form and FAQs.
  • If you have any questions about the Smokefree Community Partnership Grant please email 12 Noon Friday 7 October 2016.
  • Your questions will be answered by 5pm on Wednesday 12 October 2016. Please note that HPA may share Questions and Answers about the grant application process on the smokefree website.
  • Be aware that by lodging the application form you acknowledge that you have been authorised to prepare and submit the application on behalf of your organisation.
  • Applications are to be prepared using the Application Form included at the bottom of this document and also found at
  • Receipt of applications will be acknowledged by email. If you do not receive a confirmation email within five working days of submitting your application, please email .
  • Send your fully completed application by email only to on or before 12 Noon Thursday 20 October 2016.
  • Faxed or posted application forms will not be considered.
What happens to your application?

All applications will be evaluated by a panel comprised of HPA staff and external programme subject matter experts, against the grant evaluation criteria (listed above).

HPA may undertake a reference check of the organisation and/or named personnel in relations to shortlisted applicants. The findings will be taken into account in the evaluation process.

Smokefree CommunityPartnershipApplication Form
1.Organisation and Contact details
Organisation name: / [insert the name that you operate under]
Full legal name (if different) / [if applicable – this is the name which you are registered as a company, trust etc]
Registered office / [if you have a registered office insert the address here]
Physical address: / [if more than one office – put the address of your head office]
Postal address: / [eg, PO Box address]
GST registration number (if applicable): / [insert your GST number if applicable ]
Main contact person/Project lead: / [name of the person responsible for communicating with HPA – Note: this may be different to the person with authority to sign this application]
Position: / [job title or position]
Phone number: / [landline or mobile]
Email address: / [email address we can contact you on]
Is this a joint initiative? / No  Yes (If yes, please copy this Organisation and Contact details table and complete one for each joint applicant)
If yes, name of the lead applicant: [enter name, job title, landline/mobile numbers and email address here].
2.Describe your project

Information provided in this section will be used to assess whether your proposed project is eligible for funding.

What is the name of your project?
Brief overview (what are you aiming to achieve by implementing this project?)
Describe the activities your project will involve
Where will the project take place? / [Venue/location]
When (or over what period) will the project take place? (Note: Projects must be completed by 28 April 2017)
What are the goals of your initiative: / [eg, Community Paeroa is more aware of the dangers of smoking in cars with children]
What are the specific activities that will help you achieve your goals? / [eg, Public awareness campaign, Family open day at local marae, radio advertisements on community radio]
How will your initiative link in with the Government’s goal of Smokefree 2025? / [eg, Children are not exposed to the dangers of second-hand smoke]
How will your project meet the objectives of the grant fund and those of HPA?
What priority population groups will you engage with the project?
What changes are you likely to see in your community if your project is successful?
Describe how you intend to measure the success of your project [how will you measure your goals set out above] / [eg,250 shares in Facebook, 10 smokers sign up to stop smoking services, 20 smokers make quit attempt]
What other organisations/groups in your community are you planning to engage during your project?
3.Funding

This section sets out the amount of funding you are applying for. Reminder:you may not apply for more than $5,000 and HPA will not fund capital items (eg, building/alterations, vehicles, equipment, electronics, computers etc).

How much will your project cost? / $
Do you have other financial support or sponsorship for this project? / No  Yes (If yes, please complete table B below)
[Please list any other contributions that are not listed in the budget eg, contributions from your organisation or other sources, volunteers or donated goods]
4.Budget Breakdown

In the table below tell us how much funding you want from HPA. Don’t include costs being covered by other funders.

HPA will use the information provided in this section to understand how the funding will be applied towards the projectand to assess whether your funding application represents value for money.

Description of item / Basis of cost calculation
(eg, unit price x number of units) / Funding sought from HPA(excluding GST)
[eg, Posters] / [eg, Printing 50 posters x $2 / poster] / [eg, $100]
[eg, Venue hire for the event] / [eg, Hire cost for 8 hours @ $25/hr] / [eg, $200]
TOTAL funding sought from HPA / [eg, $300]

Table A

Please complete the table below if there are other parties who are contributing to your project.

Other parties contributing to the project / Amount funded / Is this other contribution confirmed? (Yes/No)
[Enter details here] / [Amount]
TOTAL of other funding / $

Table B

5.Referees

Please provide two referees or two references.

First Referee/Reference
Name of referee
Name of organisation
Description of relationship
Address
Telephone
Email
Second Referee/Reference
Name of referee
Name of organisation
Description of relationship
Address
Telephone
Email
6.Declaration and agreement

Here you are asked to answer questions and make a formal declaration.

Remember to get the declaration signed by someone who is authorised to sign and able to verify each of the elements of the declaration eg, chief executive or a senior manager.

Funding expectations / I/we have read and fully understand the purpose of the Fund and HPA’s objectives for making the funding available.
I/we confirm that the Applicant/s has the necessary capacity and capability to deliver the initiative described in this Application and achieve the expected benefits. / [Agree / Disagree]
Accuracy / I/we declare that in submitting the Application and this declaration the information provided is true, accurate and complete and not misleading in any material respect.
I/we understand that the falsification of information, supplying misleading information or the suppression of material information in this declaration and the Application may result in the Application being eliminated from further consideration and may be grounds for termination of any Conditional Grant Agreement awarded as a result of the invitation. / [Agree / Disagree]
Authority / I/we have secured all appropriate authorisations to submit this Application, to make the statements and to provide the information in the Application and I/we am/are not aware of any impediments to enter into a Conditional Grant Agreement to deliver the initiative this Application describes. / [Agree / Disagree]
Signing / By signing this declaration the signatory below represents, warrants and agrees that he/she has been authorised by the Applicant/s to make this declaration on its/their behalf.
Signature:
Full name:
Title/position:
Name of organisation:
Date:

Funding Application for Smokefree Community Partnership Fund 2016Page 1

[1] Statistics New Zealand (2013). 2013 Census. Available from www.stats.govt.nz

[2] I Healey et al., 2013. Youth exposure to in-vehicle second-hand smoke and their smoking behaviours: trends and associations in repeated national surveys (2006–2012). Tobacco Control, Online 17 September 2013