Primary Care Infrastructure Grants Guidelines 2011

Primary Care Infrastructure Grants sample application form

Page last updated: 2011

This is an online version of the sample application form.

ITA 342-1011

Sample application form

[Name of Applicant]
[Suburb, State/Territory]

Closing Date: 2pm (local Canberra time)
Friday 10th June 2011

  • One single-sided type-written original hard copy, two double-sided hard copies and one electronic version (on a CD) of the application must be lodged by hand, including by courier, to meet the Closing Date. This does not include the registered post service offered by Australia Post
  • The typed application should be addressed as follows:
    ITA 342-1011
    Tender Box
    Department of Health and Ageing
    Ground Floor, Sirius Building
    23 Furzer Street
    WODEN ACT 2606
Faxed and emailed applications will not be accepted. Top of page

Information and requirements for applicants

  1. Before completing this Application Form, it is recommended that you read the Primary Care Infrastructure Grants Guidelines 2011 and the Invitation to Apply (ITA) for these Grants.
  2. The information in this document is provided as guidance only.
  3. Applications can be made by individuals or organisations. There is no requirement to establish a new legal entity to apply for or receive Primary Care Infrastructure Grant funding. However, for the purpose of receiving and acquitting funding, where a consortium is involved, a lead organisation must be nominated as the applicant.
  4. There are three grant streams available to existing primary care premises providing general practice services: general practices, primary care and community health services, and Aboriginal Medical Services.

    Stream A - Grants up to $150,000
    The Objectives of these grants are to:
    1. Upgrade or extend existing premises to provide space for additional general practitioners, nurses and allied health professionals and/or students on clinical placements;
      AND
    2. Provide access to new services that meet local community health needs with a focus on preventative activities and better chronic disease management. Top of page
    Stream B - Grants of up to $300,00
    The Objectives of these grants are to:
    1. Upgrade or extend existing premises to provide space for additional general practitioners, nurses and allied health professionals and or students on clinical placements; AND
    2. Provide access to new services that meet local community health needs with a focus on preventative activities and better chronic disease management; AND
    3. Strengthen team-based approaches to the delivery of care by providing, for example, additional space for case conferencing and/or group activities such as lifestyle modification clinics and/or shared service delivery by more than one health professional; AND
    4. Provide extended hours of service where these do not exist, for example additional services in the early morning, later in the evening or on weekends.
    Stream C - Grants of up to $500,000
    The Objectives of these grants are to:
    1. Upgrade or extend existing premises to provide space for additional general practitioners, nurses and allied health professionals and/ or students on clinical placements; and
    2. Provide access to new services that meet local community health needs with a focus on preventative activities and better chronic disease management; and
    3. Strengthen team-based approaches to the delivery of care by providing, for example, additional space for case conferencing and/or group activities such as lifestyle modification clinics and/or shared service delivery by more than one health professional; and
    4. Provide extended hours of service where these do not exist, for example additional services in the early morning, later in the evening or on weekends; and
    5. Develop new, or enhance existing, clinical training facilities. Top of page
  1. Applicants can only apply for one funding stream for each existing premises / location.
  2. Applicants may partner with other organisations (e.g. a University) to make a joint application for a grant. Joint applications are permissible but only one grant is available per project.

  3. If an application is unsuccessful in one stream (e.g. Stream C) of funding; the application will not be automatically considered for another stream (e.g. Stream B) of funding.

  4. You do not need to apply for the whole amount of funding for a stream if only a portion of that amount is needed (e.g. You only need $50,000 you do not need to apply for the whole $150,000). Should you apply for less funds in a particular stream you are still required to meet the criteria for that particular stream. For example; you could apply for a grant of $50,000 under Stream A. Note that there will be no opportunity to increase the amount of the grant once the application has been lodged. You should consider the specified objectives that must be met if the application was successful under each of the Streams.

  5. Generic applications for more than one stream of grants will not be accepted.

  6. All applicants will use this application form. The extent of additional information to be supplied by applicants for Stream B and Stream C grants is indicated in this application form.
  7. Top of page
  8. Applicants should note that applications are made subject to the Conditions of Application as detailed at Item 7 of the ITA Statement of Requirements.
    Application Assessment Panels will use the following selection criteria to assess applications:
    • The potential of the proposal to achieve the Objectives as specified for each grant stream; and
    • the efficient and effective use of the funds.
    The factors considered by Application Assessment Panels in considering the efficient and effective use of the funds are as follows:
    • The relative merit of each application;
    • The geographic location of the applicant’s existing premises and the existence of similar organisations in the area capable of achieving the same outcomes;
    • The existence or otherwise of other funding sources available to the applicant;
    • Whether the premises is accredited against relevant industry and/or training standards or is progressing towards this; and
    • Contributions by other funding sources to the project which either increase the overall value of the project without increasing the value of the funds provided by the Department under this Program; or reduce the Department’s financial contribution but still achieve the same objectives. Top of page
    Ranking applications of equal merit
    Where one or more applications is found to be of equal merit, the relative merit of the applications will be determined by the Application Assessment Panel having regard to the extent to which the evidence in the application demonstrates that the existing clinic is located in an area with one or more of the following features:
    • Poor access to health services;
    • Poor health infrastructure and or coordination;
    • Where a Primary Care Infrastructure Grant could help take pressure off the emergency department of a local hospital;
    • High levels of chronic disease and/or populations with high health needs, such as large numbers of children or the elderly; or
    • High population growth or anticipated high population growth.
    In establishing the ranking, applications which demonstrate two of these features will rank higher than applications which demonstrate one of these features, and so on.
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  1. Insurance: As part of the requirements of the funding agreement, all organisations and health professionals will be required to have, or be willing to obtain if successful, appropriate levels of insurance and indemnity cover for: Workers Compensation;Public Liability and Professional Indemnity. The minimum levels of insurance cover will be negotiated with the preferred applicant.

  2. Compliance with the terms and conditions of the Funding Agreement: Please carefully review the terms and conditions in the sample funding agreement (provided in the Invitation to Apply) and confirm in Question 11 of the application form whether or not you/your organisation can comply with those requirements and if not, why not. You are advised to seek legal advice to confirm your ability to comply with the terms and conditions of the funding agreement.

  3. Confidentiality provisions: Please attach a statement to indicate whether any elements of your proposal, which may become part of any subsequent funding agreement, would be regarded as confidential, e.g. commercial in confidence. Please also provide justification for this confidentiality requirement.

  4. Declaration of any conflict of interest: Please indicate in Question 12 of the application form whether you/your organisation has a conflict of interest or potential conflict of interest that would exist if you/your organisation received funding under this Program. If a conflict of interest or potential conflict of interest exists, please attach a statement declaring the conflict.

  5. Applications must be typed using 11+ font size and include page numbers. Handwritten applications will not be accepted.
  6. Top of page
  7. This application must be lodged by hand and can include by courier. This does not include the registered post service offered by Australia Post as hand delivery cannot be guaranteed.

  8. Box sizes in this application form are indicative only and may be edited, i.e. the information provided by an applicant may take up more/less space. You can add as much information as you think is necessary to help in the assessment of your application.

  9. Applicants are required to submit one unbound signed original, two double-sided copies and one electronic version on a CD of the application (noting that the CD ROM should not contain any additional information not already provided in hard copy).

  10. Applicants can apply for funding under more than one grant stream where each application is for a different premises, located at a different site. Where an existing premises consists of a number of buildings across one or more site/s, only one grant can be applied for at that premises; and

  11. Applicants for each grant stream must complete those parts of the application form relevant to that grant stream. The Department reserves the right to decline to assess applications which do not meet this requirement.

  12. Contact Email for enquiries: email GP Super Clinics
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Verification


I verify that I have checked this application and that, to the best of my knowledge, all relevant details are correct at the time of lodgement.
[Signature of the principal officer submitting this application] and [date].
Name: [name]
Position: [position]

(and, if applicable)

I verify that I have obtained the agreement of the partners and/or co-applicants to this application and have the authority to submit this proposal on their behalf.

[Signature of the principal officer submitting this application] and [date].
Name: [name]
Position: [position] Top of page

Sample form

The sample form requests the following information:
  1. Name of applicant:
  2. Registered name (if applicable):
  3. Trading name (if applicable):
  4. ABN
  5. Organisation structure (e.g. individual/sole trader, partnership, not-for-profit entity, company limited by guarantee)
  6. Applicant street address
  7. Applicant mailing address (if the same as street address, please indicate ‘As above’)
  8. Contact person for this application - name, position, tel, fax, email address
  9. Project Manager (person with overall project responsibility) (if the same as the contact person for this application, please indicate ‘As above’) - name, position, tel, fax, email address
  10. Other persons/organisations involved in this application (if applicable)
    [Note: There is no requirement to form a new legal entity for organisations to jointly apply for funding. Organisations may be, for example, affiliates, partners or consortia.]
    List person/organisation name, address and ABN
  11. Compliance
    Does the existing premises currently provide general practice services (whether salaried or privately practising)? Yes / No
    Please review carefully the terms and conditions in the sample funding agreement applicable to the funding stream being sought and confirm whether or not your organisation is compliant with those requirements. Yes/ No Top of page
  12. Conflict of Interest
    Do you/your organisation have a conflict of interest or potential conflict of interest that would exist if you/your organisation received funding under this initiative? Yes/ No
  13. Funding Stream applied for - Stream A (up to $150,000) / Stream B (up to $300,00) / Stream C (up to $500,00)
    (tick one box only and ensure that the stream selected is consistent with the amount identified in both your application and the proposed budget)
  14. Summary of Proposal
    Taking into account the information provided in the Primary Care Infrastructure Grants Guidelines, provide a summary of your proposal e.g.:
    • The address of the premises to be upgraded or extended;
    • The proposed construction/refurbishment activities (e.g. add a room at rear of the existing premises, or connect two existing consulting rooms to make physiotherapy treatment room, or provide additional space for a student etc.);
    • The estimated cost and likely timeframe for completion of the capital works project;
    • The additional health professionals and/or students who will be supported by the upgrade or extension;
    • The new services to be delivered and how they will meet local community health needs including extended hours of service; and
    • The new or enhanced clinical training facilities to be provided.
    (Limit summary to 1 page)
    Please include
    1. Current rooms, equipment, parking etc
    2. Planned works / additions
    3. Summary of net additions / benefit to the premises and services to be provided
    Top of page

All applicants - objective 1

Objective 1: Upgrade or extend existing premises to provide space for additional general practitioners, nurses and allied health professionals and/or students on clinical placements

Provide details of the capital works project including the physical location of the project; project timeframe from commencement to completion; existing and anticipated changes to local government zoning of the premises; traffic flow and parking arrangements etc.
Please attach:
  1. a detailed capital works budget. Please note annexure 1, the Capital Works Budget template should be used;
  2. basic premises and floor plans of the existing and proposed premises that identify the planned use of each area; and
  3. photographs of the existing premises and current signage.
  4. Any other documentation, e.g. maps and details of the distance to closest Accident / Emergency Department / Hospital and other GP Services, that may assist in the consideration of this application.
[Include description]

Provide details of land/building ownership and, if applicable, tenancy details (e.g. building owned by Smith White & Associates with five year lease and five year option to extend). If the premises are not owned by the applicant, attach a letter of consent from the owner to the proposed capital works project.

Applicants are able to build on leased land, so long as the owner provides written evidence indicating they permit their building to be modified.

[Include details] Top of page

Provide details of any other organisation/s that has agreed in-principle to contribute either financially or in-kind to the project and any obligations attached to the contribution, e.g. commercial loan of $120,000 from XYZ lending institution, donation of $50,000 from XYZ community organisation, contribution of $150,000 from XYZ university as partner.

Please state clearly the source of other contributions (lender / donation / applicant to make up shortfall).

[Include details]

Provide information about other previously submitted/pending and/or potential applications made for Commonwealth grants or incentives, e.g. Practice Nurse Incentives, Access to After-hours Primary Care, Innovative Clinical Teaching and Training Grants, National Rural and Remote Health Infrastructure Grants.

[Include details]

Provide information about any overlap that exists, or may exist, with other previous or current State/Territory or Commonwealth funded projects at your premises.

[Include details]

Identify key risks to the project e.g. delays in obtaining development approval; issues relating to land transfer, traffic flow, or premises/site contamination; reliance on personal funds or bank loan to make up project budget shortfall etc. Provide advice on what activities will be undertaken to reduce or remove the identified risks. Please note annexure 2, the Risk Assessment template should be used.

[Include details] Top of page

All applicants - objective 2

Objective 2: Provide access to new services that meet local community health needs with a focus on preventative activities and better chronic disease management.

Describe the primary care services and activities your premises currently delivers and those services that you plan to deliver under this project, that focus on preventative activities and better chronic disease management.

[Include description]

Provide information about the new/expanded primary care services that you propose to provide from the premises on completion of the capital works project.

  • Describe the new/expanded services (e.g. more of an existing service/clinic, or new services enabled by additional workforce) and how these new/expanded services respond to local health needs and priorities and/or address identified service gaps. This should include:
    • the proposed recruitment strategy;
    • such demographic and/or population health data as is available to support your service needs analysis. This could be derived from the Community Atlas available from your local government authority, primary care service data available from your local Division of General Practice, or similar sources.
    • a consideration of whether the community in which the existing premises operate:
      • has poor access to health services;
      • has poor health infrastructure and/or coordination;
      • is one where a Primary Care Infrastructure Grant could help take pressure off a local emergency department;
      • has high levels of chronic disease and/or populations with high health needs, such as large numbers of children or the elderly; or
      • has high population growth or anticipated high population growth. Top of page

Grant stream B and C applicants only:

Objective 3: Strengthen team-based approaches to the delivery of care by providing, for example, additional space for case conferencing and/or group activities such as lifestyle modification clinics and/or shared service delivery by more than one health professional.

Describe the arrangements which will strengthen team-based approaches to the delivery of the services identified at Objective 3, above.

[Include description]

Objective 4: Provide extended hours of service where these do not exist, for example, additional services in the early morning, later in the evening or on weekends.

Provide information about both the current and proposed operating hours, including details of existing and/or new extended hours/activities at the premises. The extended hours should reflect the need of the local community.

For each day of the week, specify current hours of operation, proposed hours of operation, and difference + or - (e.g. +1 hour) Top of page

Grant stream C applicants only

Objective 5: Develop new, or enhance existing, clinical training facilities.

If applicable, describe existing clinical training facilities (e.g. group training room with computer terminals); and/or

Describe the proposed new or enhanced clinical training facilities (e.g. room equipped with simulation model, space for additional students, mini-auditorium, increased consulting room space to support allied health observational learning etc).

This should include details of any industry accreditation standard(s) attained or you are working towards.

[Include details]

Describe the new or enhanced clinical training opportunities that you propose to provide from the premises.

  • Provide information about any discussions with Regional Training Providers, universities and/or other clinical training organisations.
  • Provide information on any relevant training accreditation attained or you are working towards.
Applicants seeking funding to increase training capacity, who are seeking further information on training, are encouraged to contact a relevant Regional Training Provider.

[Include details] Top of page

Final Application Checklist

Before submitting your application, please ensure that you have:
  • read and considered the Primary Care Infrastructure Grants Guidelines; and
  • considered the Invitation to Apply for Primary Care Infrastructure Grants.
Please check that the following information is included in your application:
  • Signed verification page
  • Applicant organisation details pages
  • Confirmation of compliance with requirement for GP services in the existing premises
  • Confirmation of conflict of interest issues
  • Level and stream of funding
  • Summary of proposal page
  • You have provided details against each of the objectives required for the grant stream for which you are applying
You have attached:
  • Confidentiality provisions (if applicable)
  • Declaration of any conflict of interest
  • Capital works budget (using the template at Annexure 1)
  • Premises/site and floor plans
  • Photographs of existing premises and current signage
  • Land/premises owner’s letter of consent (if applicable)
  • Risk Assessment (using the template at Annexure 2) Top of page
You have provided in the application lodgement package:
  • One typed unbound signed original
  • Two double-sided copies of the application
  • One electronic version of the application on a CD (noting that the CD ROM should not contain any additional information not already provided in hard copy)
You have checked the closing time (local Canberra time) for the application.

Applications must be delivered by hand including by courier to:
ITA No.342-1011
Tender Box
Department of Health and Ageing
Ground Floor, Sirius Building
23 Furzer Street
WODEN ACT 2606 Top of Page