INNOVATION GRANTS 2015/2016
EXPRESSION OF INTEREST
Closing Date: 5pm, 7 December 2015
1. Project Title
Approximate 20 words
2. Priority Area
☐Bowel Cancer Screening: Improving Access to Colonoscopy in Public Hospitals for
National Bowel Cancer Screening Patients.
☐BreastScreen: BreastScreen: Improving access and participation in the BreastScreen
NSW Program.
☐Ovarian cancer pathways: Improving access to specialist gynaecological
multidisciplinary care in public hospitals.
Discuss how the project meets the priority area
Approximate 200 words
3. How does the project meet your organisation’s strategy?
Discuss how the project meets your organisation’s strategy
Approximate 200 words
Cancer Institute NSW in Confidence
20 October 2015
4. Project Description
Provide a brief description of the proposed project
Approximate 400 words
5. Supporting Evidence
Provide a brief description of the current evidence base which supports the proposed project
and evaluation OR justification for completing the project to fill a current evidence gap based
on a needs analysis or similar. Supporting documentation (up to 4 pages) can be attached
and will be considered part of the Expression of Interest.
Approximate 300 words
Bowel Screening applicants: Limited information is required here. Models of direct access
have been proven effective in Hunter New England and other states in Australia. If you would
like to reference published research to support your application though please do so.
BreastScreen applicants: Please add additional information here if required
CSI applicants: Localised care pathways should be based on the optimal care pathway for
women with ovarian cancer (http://www.cancervic.org.au/downloads/healthprofessionals/opc/Optimal_cancer_care_for_women_with_ovarian_cancer.pdf).
Type(s) of evidence used (please tick those used):
Publications
☐
Please provide reference list and cite appropriately above
(e.g. peer reviewed papers, reports, grey literature)
Previous projects
☐
Please include outline and organisations involved in description above
Other
☐
Please specify in description above
Cancer Institute NSW in Confidence
20 October 2015
6. Project Plan
Provide a project plan outlining key objectives you will achieve and planned activities. Please ensure SMART principles are
applied to objective setting (i.e. objectives are specific, measurable, achievable, realistic and have a timeframe). Objective
tables can be added or deleted as necessary.
Objective 1 Description:
Planned Activities:
Timeframes:
Evaluation Measures:
Objective 2 Description:
Planned Activities:
Timeframes:
Evaluation Measures:
Cancer Institute NSW in Confidence
20 October 2015
Objective 3 Description:
Planned Activities:
Timeframes:
Evaluation Measures:
Objective 4 Description:
Planned Activities:
Timeframes:
Evaluation Measures:
Cancer Institute NSW in Confidence
20 October 2015
7. Sustainability
Each application must be sustainable and/or scalable - complete the relevant section(s).
Identify how the project will be sustained after the completion of the project (i.e. how the
project will be continued over time or how the knowledge gained will be shared). Please
include consideration of cost effectiveness.
Approximate 300 words
8. Project Budget
Provide a breakdown of how the grant funds will be spent (delete/add lines as necessary).
Description
Amount
Salary/Wages (including on-costs)
Training/Education
Printing/Stationary/Administration
Travel/Accommodation
Resources
Venue Hire/Catering
Advertising/Marketing
TOTAL
In-Kind Support (if applicable)
Provide a brief summary of project “value for money” (i.e. justify the requested funding
amount based on the value the project deliverables will or could potentially offer. For
example dollars per person screened, trained, etc). If available, how does this compare with
other similar projects.
Approximate 100 words
Cancer Institute NSW in Confidence
20 October 2015
9. Administering Organisation Overview
Provide a brief overview of the organisation who will administer this project, including
organisational background, focus and current activities.
Organisation Details
Organisation Name
Street Address
Postal
Address
ABN
Overview of Organisation - Maximum 100 words
10. Current and Previous Grants
Please provide details of any current Cancer Institute NSW grants and any Cancer Institute
NSW grants awarded in the last 3 years in the nominated project area.
Approximate 200 words
11. Approval and Sign Off
This Expression of Interest requires signed evidence of support from the Project Sponsor, the
Director of Cancer Services (or equivalent), the Chief Executive / CEO and the appropriate
authority of project partner organisations.
Project Sponsor - Provide details of the Project Sponsor who will be accountable for
completion of the project and will have financial responsibility.
Title
First
Name
Last Name
Organisation
Role on
Project
Position
Title
Provide a brief explanation on how the project sponsor will be accountable
Cancer Institute NSW in Confidence
20 October 2015
Telephone
Fax
Email
Signature
Date
Project Lead - Provide details of the Project Lead who will be accountable for completion of
the project.
Title
First
Name
Last Name
Organisation
Position
Title
Role on
Project
Provide a brief explanation of role on project (eg Project
Coordinator/Manager, Lead Clinician)
Qualifications/
Experience
2-3 sentences detailing relevant qualifications and experience
Telephone
Fax
Email
Signature
Date
Director of Cancer Services (or equivalent, if relevant)
Name
BLOCK LETTERS
Signature
Date
Email
Postal
Address
Cancer Institute NSW in Confidence
20 October 2015
Chief Executive / Chief Executive Officer (delete as appropriate)
Name
BLOCK LETTERS
Signature
Date
Email
Postal
Address
Appropriate Authority of Project Partner Organisations (add further partners or delete as
appropriate)
Name
BLOCK LETTERS
Signature
Date
Email
Postal
Address
Cancer Institute NSW in Confidence
20 October 2015