(Office use only) Ref:

DRAFT

<programme of care/FUNDING STREAM>

Application Form

Closing Date:

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This application has two parts:

PART A:	About your organisation & its governance and;

PART B:	About your project and the costs

Please read the guidance notes before you fill in this form.

<INSERT CONTACT DETAILS OF RESPONSIBLE PHA OFFICER>

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Tele no:	Fax:

Email:	Website:

The Public Health Agency is committed to making information as accessible and equitable as possible and to promoting positive and meaningful dialogue with local people.

ALTERNATIVE FORMATS

In an effort to make information as accessible as possible, the application has been produced in Arial 14 pt.

The application can also be made available in the following alternative formats:

Large Print (size as required)

Computer Disk

Audio tape

Translation

For an alternative format please contact:

:

Telephone Number:

Textphone:

ADDITIONAL COPIES can be obtained by contacting:

Telephone Number:

Fax Number:

E-mail:

PART A: ABOUT YOUR ORGANISATION AND ITS GOVERNANCE

Please refer to the guidance notes while you complete this form. Answer each question in the box provided (any information disclosed will be treated in confidence). You may use additional paper if required but you must stay within the word limit, where this is indicated. Please write clearly in black ink or type.

INFORMATION ABOUT YOUR ORGANISATION

Question 1

Name of your

Organisation:

Address,

including full postcode:

If your organisation has a website please write the address here:

Mr/Ms/Mrs/Miss/Dr:

Name of main contact

for your organisation (the person we should

communicate with):

Position held in organisationgroup:

Contact address if

different from above,

including full postcode:

Phone: Daytime	Fax no:

E-mail address:

If you have any

particular

communication

needs, tell us

what they are.

Question 2

When was your organisation set up?

Month	Year

Question 3

If your organisation is a branch of a larger organisation or a member of an umbrella body please tell us which one:

Question 4

What type of organisation/group are you?

A statutory organisation

A Social Enterprise Organisation

Unregistered charity, club, society or association, community based group or organisation

Organisation recognised by HM Revenue & Customs (previously known as Inland Revenue) as charitable for tax purposes

Charity Registered with Charity Commission in NI

Charity registered in England or Scotland (OSCR) or Wales

Registered Charity No:
Date of Registration:
Company Limited by Guarantee No:
Date of Registration
VAT registration number

Question 5

How many people are involved in governance and management of your organisation?

Committee and/or Board	Volunteers (unpaid)

members

Paid staff: Full time	Paid staff: Part time

Question 6

Briefly describe the main aims and activities of your organisation and/or what services your organisation provides? (Maximum word limit 250).

Financial Controls

Failure to answer questions 7- 9 fully and satisfactorily will result

in your application being rejected.

Question 7

Your organisation must have a bank account.

Please provide details below:

Account Name
Bank or building society name
Bank or building society address
Sort Code
Account Number

Question 8

Who is authorised to sign cheques?

There must be at least two authorised signatories

Name:	Position in Organisation:

Are any of the signatories related to each other?

Yes:	No: 	If Yes, please provide details below:

Question 9

A. Your organisation must have the following systems and procedures in place, which can be made available for inspection within 7 working days upon request. Failure to answer affirmatively will result in your application being rejected:

Financial Controls – A written policy on its:	Yes	No
Cash handling arrangements
Arrangements for banking
Arrangements for purchasing goods and services
Arrangements for delegating authority
Systems for regular bank and cash reconciliation
Record of income and expenditure transactions
Cheque books and receipts which are held in a safe/cash box to which access is strictly controlled
Arrangements in to respond to a suspected fraud within your Organisation
Necessary insurance cover for public liability, employer liability, property/contents – where applicable
A policy in writing whereby no one person can order, receive and pay for goods and services (segregation of duties)
Travel and Subsistence Policy (where applicable)
Have all of the above systems been approved by the management committee?

B. Are all of the above regularly reviewed?	Yes	No

How often are they reviewed eg quarterly/annually? _________________

C. If your organisation has a computer do you have IT security procedures eg, regular backups, password protection?

Yes	No:	Not Applicable

D. Your organisation must have policies in place to assure compliance with the law for the following. If you do not currently have these policies they must be in place prior to funding being allocated:

Policies & Procedures Checklist	Yes	No
Health and Safety Policy
Equal Opportunities Policy
Child Protection Policy
Vulnerable Adults Policy
Freedom of Information
Data Protection Policy

PART B:	ABOUT YOUR PROJECT AND THE COSTS

Please refer to the guidance notes while you complete this form. Answer each question in the box provided (any information disclosed will be treated in confidence). You may use additional paper if required but you must stay within the word limit, where this is indicated. Please write clearly in black ink or type.

(Office use only) Ref:

INFORMATION ABOUT YOUR PROPOSAL/PROJECT

Question 10

Name of Project:

How much is your organisation applying for from this funding?

£

Question 11

What is the Project location and geographical coverage? (please complete all 3 boxes if project is targeting a specific ward(s))

Local Commissioning Group / Trust Area

Local District Council Area(s)

Ward Area(s)

Question 12

Please tell us how the targeted population will benefit from the project (include the number of people to benefit). Tell us what measurement tools you will use to measure these benefits: (Maximum word limit 450).

Question 13

Provide evidence that your project will address a local need (e.g. local

analysis, research etc): (Maximum word limit 450).

Question 14

Give a summary of the project, detailing aims and objectives (word limit 300):

Question 15

How does your project correspond to the priorities / targets and specification for funding? Please take each criteria point separately and detail how you propose to deliver each of the service requirements. (see guidance notes)

Question 16

Detail the outcomes you hope to achieve through this project and how these will be measured.

Outcomes	Proposed Method for Measuring
1.
2.
3.
4.
5.
6.

Question 17

Detail the actions your organisation will undertake to achieve these aims / objectives. The total number of individuals, or families or groups etc who will be provided with a service within in the Project/Scheme must be included: (E.g. Club once per week between the hours of 7pm – 9pm for 25 people aged 35+ at Venue, 48 weeks per year). (Note these will be regarded as performance indicators which will be included as part of performance monitoring, should your application be successful).

Please complete details below for each different Programme/Activity. The TOTAL is the total for all Programmes/Activies.
Activity (please include location, day(s) of week and age group)	Number of Sessions per Week (a)	Number of Weeks per Year (b)	Total Sessions in Year (a) x (b)	Total Hours in Year	Attenders per Session	*Attendances/ Interventions in Year
E.g. Club	1	48	48	96	25	1200
TOTAL

Note:

*Attendances/Interventions is the number of Attenders multiplied by the number of sessions

Question 18

When will you start your project ____________________

Will you be able to complete your project within the specified funding period:

Yes	No

Question 19

What impacts do you expect the project to have beyond the funding award period?

Question 20

How will the project avoid duplication with existing services/organisations and what are the arrangements for collaborative working with other providers and the target community?

Question 21

How will you address inequalities in health and social exclusion?

Question 22

How have beneficiaries/service users or local people, been or will be involved in the design / implementation / management of the project to allow engagements and ownership?

Question 23

Have you addressed the sustainability of the project, or developed an exit strategy? If so, please detail; if not, explain why.

Question 24

Please indicate your relevant/recent (3/5 years) experience in the management and delivery of similar projects:

Question 25

Have you identified any risks or uncertainties that are associated with your project/service? How do you propose to manage them?

Question 26

Please tell us about how you intend to share the learning from this project with colleagues in the field of health and social well-being, voluntary groups and community groups and networks in your locality to influence policy and practice.

Question 27

Does your project/service involve partnership across the statutory, voluntary & community sector? If so please give details:

Partner	Contact Details	What is their role / responsibility

Question 28

Will any other organisation be involved with you in delivering this project/service? If so, describe the nature of the management agreement. Enclose a copy of the agreement if available.

FINANCIAL INFORMATION	ABOUT YOUR ORGANISATION AND PROJECT

Question 29

Please indicate other health and social well-being related projects that the organisation is currently in receipt of or seeking funding for, from the Health and Social Care Board, Public Health Agency, Health & Social Care Trusts or any other sources:

Project	Total Cost	Funding Source	Status

Question 30

Has your organisation applied to any other agency for funding in relation to this proposal. Yes	No

If yes, please provide details of the organisation, amount sought and the status of your application i.e. funding secured – letter of offer received, application being processed, application to be made or contribution will be in kind.

Question 31

Who will be responsible for managing the finances of this project/service? – Provide contact details

Question 32

Please provide a detailed breakdown of all costs you are seeking funding for using the following pro forma. Please ensure that you also provide a breakdown and rationale for each of the costs. This proforma will be used to determine your award criteria score for costs.

Salary costs per post	£	Rationale for costing
1. Job Title
2. Salary
3. Employer’s NIC
4. Employer’s Pension
5. Total Salary Cost (annual) (i.e 2+3+4)
6. Hours Worked

Programme costs (detail)	£	Rationale for costing
Project running costs & overheads	£
Travel
Rent and Rates
Heat, light and power
Telephone
Postage
Printing and Stationary
Capital costs (if any – detail)
Other expenditure (eg) Job Advertising
Total Expenditure (annual)	£

REFEREE

Question 33

Please tell us about someone who can tell us more about your organisation and its work. This person should be independent of your organisation i.e. should not be a member, trustee, beneficiary or a relation.

Name

Occupation

Contact address, including full postcode

Phone: Daytime	Evening

This person must be willing to be contacted and know this organisation and its work and if necessary provide written confirmation of support for this application if successful.

CHECKLIST

The following information must be submitted along with your application

form. Failure to submit details in relation to a-e below will result in

your application being automatically rejected.

a copy of the governing document of the organisation (may include set of rules or memorandum, constitution, rules, articles of association or set of rules defining the aim, objectives and operation procedures for your group) dated and signed, as adopted; If your organisation is a statutory body a signed Statement of Internal Control is required;
a copy of the organisation’s most recent signed audited/unaudited annual accounts; or for new groups, statement of income and expenditure, which are signed by an office holder or auditor;
a copy of your most recent bank statement ; and
a list of current committee members/trustees/directors indicating if they represent other organisations/groups or if they serve in an individual capacity
Organisational chart clearly demonstrating management structure, accounting and governance arrangements for project

This application must be signed by Chairperson, Chief Executive/or most senior staff member and a trustee or senior colleague.

DECLARATION

All the information given is correct and complete.

Please sign below

Signed:	Signed:
Print Name:	Print Name:
Position:	Position:
Date:	Date:

The information on this form may be made available to other government departments/agencies/other funding organisations. (Bank details excepted) for the purpose of the prevention of double funding or other irregularities and in the interest of public accountability.

Check that you have fully answered all the questions and supplied all the relevant information. The Commissioner reserves the right to reject any application that is incomplete.

Please send your completed application to:

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Please remember to keep a copy of this application for your own use.