Date Application Received:
/
Office Use Only
/ 2014
Application Number:
Application Form
Request for Offers
Domestic and Family Violence Services
2014-2015
Please select one Service Outlet Location and each Service Type for which this Offer relates:
Region
Service Outlet Location
Service Type
North
Queensland
Burdekin
Counselling & Support (T320)
Court Support (T321)
Hinchinbrook
Counselling & Support (T320)
Court Support (T321)
Charters Towers/Flinders
Counselling & Support (T320)
Children’s Counselling & Support (T315)
North Coast
Townsville – Counselling
and Support
Counselling & Support (T320)
Townsville – Local
Service Systems
Local DFV Service Systems (T437)
Sunshine Coast –
P.R.A.D.O
Counselling & Support (T320)
Sunshine Coast –
Children and Perpetrators
Children’s Counselling & Support (T315)
Redcliffe
Counselling & Support (T320)
Children’s Counselling & Support (T315)
Perpetrator Intervention Programs (T328)
Children’s Counselling & Support (T315)
Court Support (T321)
Pine Rivers
Counselling & Support (T320)
Children’s Counselling & Support (T315)
Court Support (T321)
Brisbane
Brisbane North
Local DFV Service Systems (T437)
Counselling & Support (T320)
Children’s Counselling & Support (T315)
Court Support (T321)
Perpetrator Intervention Programs (T328)
Grant Funding Application Form - Department of Communities 2011
South West Brisbane
Local DFV Service Systems (T437)
Counselling & Support (T320)
Children’s Counselling & Support (T315)
Court Support (T321)
Perpetrator Intervention Programs (T328)
South East
Redlands
Local DFV Service Systems (T437)
Counselling & Support (T320)
Children’s Counselling & Support (T315)
Court Support (T321)
Perpetrator Intervention Programs (T328)
South West
Goodna/Springfield/
Lockyer Valley
Counselling & Support (T320)
Toowoomba and Darling
Downs
Counselling & Support (T320)
Name of Offeror:
Name of Proposed Service:
Please tick box below to mark this Application Form as:
Original
Copy 1
Copy 2
Copy 3
Children’s Counselling & Support (T315)
Application Form - Department of Communities, Child Safety and Disability Services 2014
Contents
1.
Completing the Application Form
2.
Offeror Details
3.
Proposed Service Details
4.
Information when Preparing the Budget
5.
Offer Summary
6.
Assessment Criteria
7.
Organisation Agreement
8.
Lodging the Application
9.
Application Checklist
Please read this Application Form and the accompanying Tender Specification document
carefully before completing and lodging your application.
Should you require further information regarding the completion of this Application Form please
contact violence_prevention_team@communities.qld.gov.au.
Privacy Notice
The Department of Communities, Child Safety and Disability Services is collecting
information, including personal information, on this form for the purpose of assessing this
application. Your personal information will only be accessed by authorised departmental
officers for purposes directly related to assessing this application.
Your personal information will be managed in accordance with the Information Privacy
Principles outlined in the Information Privacy Act 2009.
The department generally provides local Members of Parliament with the contact details of
organisations approved for funding.
Should this application be successful, some of the information in this form will be provided to
local Members of Parliament for the purpose of promoting and reporting on the funding
approved for your service.
Application Form - Department of Communities, Child Safety and Disability Services 2014
1. Completing the Application Form
To help you complete this form, please ensure you have obtained and read the following
departmental document:
 Domestic and Family Violence Services – Tender Specifications 2014-2015
The Tender Specification document is available from the Department of Communities, Child
Safety and Disability Services’ website:
http://www.communities.qld.gov.au/gateway/funding-and-grants/funding-available
Eligibility
Offerors must be eligible to receive funding from the Department of Communities, Child Safety
and Disability Services. Refer to Section 2: Organisational Details.
Assessment
Applications will be assessed according to Legal Status (Section 2) and Assessment Criteria
(Section 6) and in consideration of local needs and existing service provision.
Duration and continuation is dependent on available budget, government priorities, a need or
demand for the service type and a demonstrated capacity by an organisation to deliver the
required services, outputs and outcomes for service users.
Where required, Offerors may be asked to provide further details or provide clarification of their
Offers during the assessment process. This may include a presentation of the proposed service
model by Offerors to departmental representatives.
Completing the Application Form
 All sections of this funding application form must be completed.
 Keep your answers concise by observing the word limits on selection criteria.
 Applicants may attach only those letters from collaborative partners that state how their
agency collaborates with the work your agency is undertaking in this initiative.
Lodging the Offer
 Please lodge your Offer in hard copy, ensuring that an original and three copies
(including supporting material and attachments) are provided. The application marked
‘Original’ must be unbound.
 If you are not using an electronic version of this document, please attach additional
pages sufficient to provide adequate information.
 This Application Form is for one Service Outlet Location only. A separate Application
Form must be completed for each service for which the organisation wishes to tender.
 Any Offers that are linked or interdependent on other Offers in this process and which
need to be considered together, should be identified to enable joint assessment.
Does this Offer need to be assessed jointly with another Offer?
Yes
No
If yes, please identify the linked Offer/s (i.e. name and location of Offeror/s and/or proposed
service/s).
1.
2.
3.
Application Form - Department of Communities, Child Safety and Disability Services 2014
2. Offeror Details
2.1.1 Offeror Details
Name of Offeror:
Registered Address of the Offeror:
Postal Address:
Telephone Number:
E-mail Address:
Fax Number:
Australian Business Number:
Yes
GST Registered
No
2.1.2 Contact Officers
Title
Name
Position
(eg, Mr Mrs, Ms)
Telephone
(Business Hours)
2.1.3 Office Bearers (list at least two)
Title
Name
(eg, Mr Mrs, Ms)
Position
Telephone
(Business Hours)
2.2 Legal Status
Please advise the legal status of the Offeror:
An incorporated not-for-profit organisation:Queensland Associations Incorporation Act 1981
Queensland Religious, Education or Charitable Institutions Act 1861
Commonwealth Corporations Act 2001 (non-profit objectives)
Queensland Co-operatives Act 1997
Local Government Authority
Commonwealth Aboriginal Councils and Associations Act 1976
Commonwealth Corporations (Aboriginal and Torres Strait Islander)
Act 2006
Queensland Local Government (Community Government Areas) Act 2004
Queensland Community Services (Torres Strait) Act 1984
Queensland Aboriginal Communities (Justice and Land Matters) Act 1984
An organisation with non-profit objectives incorporated by an Act of Parliament
An incorporated for-profit organisation
Other (please provide details)
Has a copy of the Offeror’s certificate of incorporation/registration been
attached to this Offer?
If no, please provide details below.
Respond here:
Yes
No
Application Form - Department of Communities, Child Safety and Disability Services 2014
2.3 Current Funding
Does the Offeror currently receive funding (or has it in the last two years)
from the Department of Communities, Child Safety and Disability Services?
If yes, please provide details below.
Respond here
Has the Offeror provided all relevant reports and accountability
requirements for funding previously provided by the Department of
Communities, Child Safety and Disability Services or previous Department
of Child Safety or its predecessors?
If no, please provide details below
Respond here
Yes
No
Yes
No
Offerors that are not currently funded by the Department of Communities, Child Safety and
Disability Services may wish to provide the names and contact details of two referees. 1
1.
2.
Has a copy of the Offeror’s most recent audited financial statement been
attached to this application?
If no, please provide details below
Respond here
Does the Offeror currently receive other funding from the Commonwealth,
State or Local Government to provide services similar or relevant to this
procurement proposal?
Yes
No
Yes
No
If yes, please specify the source, funding program, duration (financial
years) and amount of funding.
Funding Source
Funding Program
Duration
(years)
Amount
Has the Offeror submitted a tender for a proposed service similar to the
one contained in this Offer within the last two years?
Yes
No
If yes, please provide details below.
Respond here
1
Offerors should note that the department reserves the right to make inquiries in respect of applications
for funding from either specific nominated referees (where provided) or from whatever source the
department thinks fit.
Application Form - Department of Communities, Child Safety and Disability Services 2014
Does the Offeror hold a minimum of $10M Public Liability Insurance for this
service/project/event?
If yes, please provide the following details:
Sum insured
Yes
No
$
Expiry date of policy
Date:
If no, your organisation will need $10M public liability insurance for any activities funded by
the Department of Communities, Child Safety and Disability Services. Please provide details
on how the Offeror plans to obtain insurance. Include details on cost, name/s of provider/s
from whom quotes have been obtained and amount to be insured:
Respond here
3. Proposed Service Details
This section will inform the department about your proposed service.
3.1 Service Details
Service Name:
Address of premises from which the
service will be provided (if address is
unknown as this stage please indicate the general
location).
Postal Address
Telephone Number
E-mail Address
Fax Number
Address of premises from which the
service will be coordinated / managed
(if different from the organisation and service
addresses).
Postal Address
Telephone Number
E-mail Address
Fax Number
3.2 Agents with which your service will collaborate (where relevant) 2
2
Organisation/Offeror
Name
Contact Name
Address
E-mail
Collaborative agents are organisations or individuals which have agreed to assist your organisation with
the proposed service. Please attach a letter or other evidence from the agency or person which outlines
their support and their contribution to this application.
Application Form - Department of Communities, Child Safety and Disability Services 2014
Telephone Number
Describe how this
collaboration will
improve and enhance
service delivery
Organisation/Offeror
Name
Fax Number
Contact Name
Address
E-mail
Telephone Number
Fax Number
Describe how this
collaboration will
improve and enhance
service delivery
(if necessary, please attach additional list)
4. Information when Preparing the Budget
The total funds available as outlined in the Tender Specifications reflects the level applicable for
the 2014-15 fiscal year covering all of the identified Service Outlet Locations.
The Offeror’s budget, provided in response to Assessment Criteria 5 (Value for Money) in
Section 6 below, should be on an annual basis (full year effect) for a period of up to three years.
Contracts are usually negotiated for periods up to three years.
The selection panel is willing to consider small, one-off establishment costs in addition to the
budget.
Costs eligible for inclusion in the budget include:
 purchase of assets, set-up and other one-off costs;
 salary-related costs for staff directly involved in the delivery of the service or the
administration and coordination of the service; and
 operating costs directly related to the delivery of the service
 costs associated with certification under the Human Services Quality Standards.
Budgeted costs should exclude GST. Payments made by the department to organisations that
are GST registered will be fully grossed up by 10% when funds are advanced.
5. Offer Summary
Please provide a brief summary below (1,000 words maximum) describing the major features
of the content provided in your application. The summary should reflect the content described
in each of the assessment criteria, budget highlights and any other matters related to the
application.
Respond here
6. Assessment Criteria
The department will assess all applications against each of the following assessment criteria,
weightings and local needs and priorities. Please note carefully, the attachments are not
included in the page limit of the application which must not exceed 25 pages in total. You
must ensure that your responses and supporting documents are specifically relevant to the
assessment criteria.
Application Form - Department of Communities, Child Safety and Disability Services 2014
Criterion 1 UNDERSTANDING OF DOMESTIC AND FAMILY VIOLENCE (4 weighting)
Describe the Offeror’s understanding of issues related to domestic and family violence
and the practice approaches and standards associated with service delivery to people
affected by domestic and family violence.
Supporting evidence should include:
 understanding of the needs, issues and interests of people affected by domestic and
family violence and how this understanding would be reflected in the services proposed to
be provided;
 understanding of the dynamics of domestic and family violence and its impacts on families
and individuals, in particular children and young people;
 understanding of the interface between domestic and family violence and family support
and child protection and how this understanding is reflected in the services provided; and
 identification of the practice approaches in delivering domestic and family violence support
services, including in a family support context.
Respond here
Criterion 2 SERVICE MODEL and CULTURAL APPROPRIATENESS (5 weighting)
Describe the proposed model of service delivery, how it will meet the intended purpose
of the domestic and family violence service and deliver the required outputs, including
ability to appropriately meet the needs of Aboriginal and Torres Strait Islander peoples
and people from Culturally and Linguistically Diverse backgrounds.
Supporting evidence should include:
 service users who will be using the services;
 target group to benefit from the service;
 operating hours;
 how the service will support service users across the geographic catchment area/s;
 service approach to risk assessment, risk management and safety planning;
 engagement strategies with service users, including those referred without consent;
 service approach to recognising and responding to the specific needs of the target group
including Aboriginal and Torres Strait Islander people and people from culturally and
linguistically diverse backgrounds and the approach to be taken to improve delivery of
services to a culturally diverse target group;
 referral sources including key government and non-government agencies;
 the practice principles (e.g. access and equity, valuing diversity) to be used to deliver a
culturally competent service; and
 capacity to recruit workers that hold professional qualifications and/or experience working
with people affected by domestic and family violence.
Respond here
Criterion 3 CAPACITY and COMMENCEMENT (3 weighting)
Describe the Offeror’s capacity to deliver the proposed domestic and family violence
service and ability to start service delivery no later than 1 March 2015.
Supporting evidence should include:
 awareness of, and participation in, the Queensland domestic and family violence service
system;
Application Form - Department of Communities, Child Safety and Disability Services 2014








awareness of the role of domestic and family violence services in supporting the families
of children and young people to prevent their entry or re-entry into the statutory child
protection system;
evidence of the Offeror’s experience in delivering, or ability to deliver, innovative
domestic and family violence services that meets the contemporary needs of
Queenslanders
staff skills, experience and qualifications;
understanding of the counting rules for performance reporting, particularly in relation to
output hours;
hours of direct service delivery to clients and hours of indirect service provision;
number of days or weeks per year direct service delivery will be provided to service users
that count towards output reporting;
number of staff proposed to be involved in direct service delivery to service users; and
milestones and timelines demonstrating how the service will be able to provide direct
service delivery from 1 March 2015.
Respond here
Activities/Tasks/Phases
This includes the tasks to
establish and deliver the
service.
Milestones/Date/Timeframe Performance Indicators/
Measures/ Targets
Including commencement and
completion dates of different
activities.
Including how it will be known
that activities have been
achieved.
Criterion 4 COLLABORATION (5 weighting)
Demonstrated capacity to work collaboratively with other community and government
agencies to provide responsive and coordinated services.
Supporting evidence should include:
 examples of collaboration involving the Offeror that promoted innovation and flexible
approaches to improve system responses for service users;
 demonstrated commitment to working to provide an improved, integrated response to
individuals and families impacted by domestic and family violence;
 the Offeror’s ability to work collaboratively with other support services in surrounding
areas, including CBIR and IFS services;
 ability to contribute to the network of domestic and family violence prevention and support
services in the area;
 ability to actively engage with and contribute to the Local Level Alliance led by a CBIR
service; and
 capacity to develop collaborative partnerships to enhance the organisation’s ability to work
with Aboriginal and Torres Strait Islander communities and culturally and linguistically
diverse communities.
Respond here
Application Form - Department of Communities, Child Safety and Disability Services 2014
Criterion 5 VALUE FOR MONEY (3 weighting)
Provide information about the service budget and how the Offeror’s service model has
been costed. In particular, demonstrate how the proposal represents value for money.
Provide a detailed explanation of how the costings for the Offeror’s service model were
developed and the rationale for employing staff in their proposed roles, including brief
descriptions of how their duties and the workforce structure will result in better and more cost
effective outcomes for service users. Rationale is also required for operating costs requested
in the Application Form.
Consider other factors such as existing networks, local knowledge and service experience
and other value provided through the Offeror’s resources.
Respond here
Description
(for information on cost items see Guide to Cost Item
Expenditure Categories in Attachment 1)
Annual Funding
full year effect
whole dollars only
Defined term costs
Salaries
$
Other
$
TOTAL
$
One off costs
Assets
$
Set-up costs
$
Other
$
TOTAL
$
Application Form - Department of Communities, Child Safety and Disability Services 2014
7. Offeror Agreement
I understand that should this Offer be successful the organisation will be required to:
 enter into a Contract with the department
 comply with the Department of Communities, Child Safety and Disability Services
conditions as contained in the Contract
 participate in performance monitoring processes
 participate in data collection
I declare and certify that:
 I am authorised by the applicant organisation to make this Offer
 the details in the Offer are accurate; and
 sufficient control mechanisms are in place to ensure that all monies can be managed
and accounted for appropriately
On behalf of the Offeror:
Signed
Name:
Organisation Position: (authorised officer)
Date:
8. Lodging the Offer
Closing Date: All Offers must be lodged by 4.00pm Monday 3 November 2014. Late Offers
may not be accepted.
Offers submitted by email, fax or scanning documents will not be accepted.
Offer Requirements: Copies of the following documents must be included in your Offer.
Please check the box to indicate that the documents are attached:
a completed original unbound Application Form signed by an authorised office holder
letters of support from collaborative agents (where relevant)
any additional relevant information to support the application
three additional copies of the full application and its attachments.
Enquiries: The contact officer for this tender specification is Mr Nigel Noall, Principal
Program Officer, Violence Prevention Team, Community Service and Industry
violence_prevention_team@communities.qld.gov.au. Questions relating to the information in
this paper should be submitted via the Yammer Group – Domestic and Family Violence
Services Tender Specifications 2014-15 – and will be responded to on Yammer for all group
members to access. Advice will not be offered on individual applications.
Lodging Applications:
Offers should be clearly marked and posted to –
OFFER FOR DOMESTIC AND FAMILY VIOLENCE SERVICE – 2014
The Queensland Government Tender Box
c/o Decipha
Tender Box No. D&FVSI-2014
GPO Box 2482
Brisbane QLD 4001
The Offer must be submitted in a SEALED ENVELOPE or PACKAGE which is clearly
labelled with the information below. You should complete and attach the label below to your
envelope or package.
Application Form - Department of Communities, Child Safety and Disability Services 2014
Application Envelope / Package Label
 --------------------------------------------------------------------------------------------------------------------------------The name of the Funding Initiative:
Domestic and Family Violence Services
2014-15
The Funding Initiative tender number:
D&FVSI-2014
Inviting agency name:
Department of Communities, Child Safety
and Disability Services
Contact officer’s name:
Nigel Noall
The closing date and time for lodgement of
application:
4.00pm Monday 3 November 2014
The applicant’s name, address and contact
details:
Application Form - Department of Communities, Child Safety and Disability Services 2014
9. Checklist
The purpose of this checklist is to help ensure you have answered all the questions in the
Application Form and have attached the required supporting evidence. Please ensure you
have completed all sections of the Application Form.
Section 1 – Completing the Application Form
Have you completed one Application Form for each service outlet location for which you are
tendering?
Section 2 – Offeror Details
Have you provided details of contact officers for this Offer?
Have you provided details of the Offeror’s office bearers?
Have you provided details of the pubic liability insurance held by the Offeror?
Have you provided a copy of the Offeror’s incorporation certificate?
Have you provided a copy of the Offeror’s most recent audited financial statement?
Section 3 – Proposed Service Details
Have you provided details of the proposed service?
Have you listed the agents with which your service will collaborate and any support letters?
Section 5 – Offer Summary
Have you completed the Offer Summary?
Section 6 – Assessment Criteria
Have you provided a response to each assessment criterion?
Have you provided a proposed budget for the service, considering the information provided in
Attachment 1?
Section 7 – Offeror Agreement
Has the Application Form been signed by an authorised officer of the Offeror?
Section 8 – Lodging the Offer
Have you provided an unbound original and three copies of the full Offer and attachments?
Have you kept a copy of the Offer for your records?
Application Form - Department of Communities, Child Safety and Disability Services 2014
Attachment 1
Guide to Cost Item Expenditure Categories
Key information to consider when planning your budget in Criterion 5
Annual Funding
full year effect
whole dollars only
Budget item description (See tables below for information on budget
items)
A. Sub total salaries (Total A from ‘Salary Table’ below)
$
Other cost items (See ‘Guide to Other Costs Table’ below).
Administrative costs $
Property and Energy costs $
Motor Vehicle costs (must be essential to service delivery) $
Travel and Training costs $
Client Related costs $
B. Sub total of other costs
$
One off costs (See ‘Guide to One off Costs Table’ below).
Assets (provide details in Asset table below)
(Total B from ‘Asset Table’ below) $
Set-up expenses)
$
C. Sub total one-off costs:
$
Total funding requested: (A + B +C)
$
Explanation of budget items (where necessary)
Tables and Guides to assist in completing your budget
Salary Table
Position Title
Full / Part
Time Status
Salary
Total Base
Salary
On-costs
$
$
$
$
$
$
$
Super
Penalties
Total Salary
FYE
$
$
$
$
$
$
$
$
$
$
$
Application Form - Department of Communities, Child Safety and Disability Services 2014
$
$
$
$
Total:
Directions for above table:
$
TOTAL A
Position Title:
separate line for each position
Salary:
annual base salary
Total Base Salary:
status X salary
On-costs:
includes sick leave, workers compensation, recreation leave loading, recreation
leave - staff cover, casual loading
Super:
9% of Total Base Salary
Total Salary FYE:
Total Base + On costs + Super + Penalties
Guide to salary related costs
Salary related expense items
Salaries and wages
All salaries and wages (including penalty payments) paid to all staff
employed on a permanent or casual basis (including
temporary/replacement staff), included, but not limited to salaries, wages,
annual leave, long service leave, sick leave, salary sacrifice,
superannuation, workers’ compensation and fringe benefits tax.
Contract workers
Consultancy fees paid in respect of contractors engaged in direct service
delivery only.
Other expense items not related to
salary
All other expense items in the Standard Chart of Accounts.
https://wiki.qut.edu.au/display/CPNS/National
Guide to other costs
Administrative costs
Accounting fees, advertising and promotion, audit fees, bank charges and
fees, consultancy fees, fees and permits, licenses, loans, subscriptions and
memberships, insurance premiums – general, insurance premiums – public
liability, insurance premiums – professional indemnity, insurance premiums –
volunteers, postage, freight and courier, telephone, fax and internet charges,
printing and stationery, publication and information resources, sundry
expenses.
Property and energy costs
Cleaning, equipment hire/lease, property management fees, rates and taxes,
rates rental properties, rent – rental properties, repairs and maintenance
equipment, repair and maintenance rental property, cleaning, property
rent/lease, council rates, utilities (electricity and gas), security expenses, staff
amenities.
Motor vehicle costs
Fuel and oil, repairs and maintenance, motor vehicle insurance premium,
registration, motor vehicle lease payments. Do not include vehicle purchase
costs.
Travel and training costs
Employment support and supervision, training and development staff, travel
and accommodation, volunteer costs.
Client related costs
Client support costs, client support consumables including emergency relief
payments, food for service delivery, general client related expenses,
program/activity expenses.
Application Form - Department of Communities, Child Safety and Disability Services 2014
Guide to one off costs
Assets
Those capital items with a purchase price of $5000 or more and a useful life of
more than 12 months. Includes motor vehicles, furniture, whitegoods, plant
and equipment.
Repairs and maintenance, including minor building modifications (<$5000)
Set-up expenses
Assets purchased <$5000, including office furniture, equipment and
computers/software.
Salary and wages without recurrent implications arising from establishing the
service/project.
Asset Table
Asset description
Total:
Funding sought
Estimated purchase
price
$
$
$
$
$
$
$
$
$
$
$
Total B
$
Estimated purchase
date