Unsolicited Proposal - Application Guide and Form

Please complete the form here and we will be in touch regarding your request.

Organisational Legal Entity

Organisational Trading Name

Registered for GST

ABN

Representative / CEO

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone

Mobile

Primary Contact

Primary Contact Email

Primary Contact Mobile

Commencement Date

End Date

Location of Project (town or region)

Name of Project

1. PROPOSAL BACKGROUND- please provide a summary of the proposal, region and target population need and how your proposal will contribute to improving the health and wellbeing of country South Australians (Maximum 400 words)

2. CSAPHN PRIORITIES- please identify how the proposal fits within and addresses the CSAPHN strategic priorities and the Quadruple aim. (Maximum 200 words)

3. PROPOSAL AND OUTCOME INDICATORS- please outline how the proposal will impact health outcomes and how these will be measured (Maximum 400 words)

4. APPLICANT CAPACITY - please provide information about your capacity to deliver the proposed activities, including relevant governance arrangements, accreditation status, staffing and resources. Please describe how you will ensure the necessary protocols and procedures are in place to ensure services are delivered in a culturally appropriate way. (Maximum 200 words)

5. STAKEHOLDERS AND PARTNERS- please provide details regarding stakeholders consulted and involved in this proposal and their roles and responsibilities. Include any proposed steering or partnership arrangements (Maximum 200 words)

6. INNOVATION AND SUSTAINABILITY- please describe how this proposal will work to build innovation and sustainability into the service. (Maximum 200 words)

7. FUNDING AND BUDGET

Proposal Funding Requirement

Enter total per annum (ex GST)

Proposed CSAPHN Funding

Enter total per annum (ex GST)

Please list all non-CSAPHN project funding, including any in kind contributions.

Contributor

Amount (ex GST)

Status

Contributor

Amount (ex GST)

Status

Contributor

Amount (ex GST)

Status

8. ADDITIONAL INFORMATION- please provide any additional information that you feel necessary for a comprehensive assessment Attach any relevant documents as required.

9. REFERENCE LIST- if required please provide a complete list of references mentioned above.