Application Form

Primary Health Care Vaccination Grants Program 2025 - Priority Populations - Outreach Clinics

Funding is available for general practices, Aboriginal Medical Services, and pharmacies currently offering COVID-19 vaccinations to deliver outreach clinics to priority community groups who are not currently accessing vaccination services.

Applications will remain open until 5:00pm, Monday 20 June 2025.

Applicants are required to read the Application Guidance before applying. Submission of a signed online application does not guarantee funding. WNSW PHN reserves the right to request changes to the proposed activity prior to approval.

Funding of up to $14,000 (excluding GST) will be made available per each application.

All activities must be completed within three months.

APPLICATION DETAILS

Legal Name of Organisation: *

Trading Name of Applicant (if applicable):

Do you have an ABN? *

Yes No

ABN: *

Are you registered for GST? *

YesNo

If Other, please specify *

Street address *Street address line 2

City *

State *

Postcode *

Briefly describe your organisation (no more than one paragraph) *

APPLICATION CONTACT DETAILS

In this section you are asked to provide contact details of your organisation's authorising officer and/or key contact person for this application. The authorised contact person is the person who is authorised to sign a funding agreement on behalf of your organisation, should your application be successful.

Authorised Person’s name: *

Authorised Person's Position title: *

Authorised Person's Email Address *

The application contact should be the person we will contact for any issues related to the application and project activity:

Application contact person: *

Application contact person position title: *

Contact Person's Email Address *

Contact Person's Phone number: *

ELIGIBILITY CRITERIA

Please select the type of primary health care association *

General PracticeAboriginal Medical Service Pharmacy

Registered with the relevant governing body ie. AHPRA *

YesNo

Authorised immunisation provider and comply with NSW Health legislation within the Western NSW PHN region. *

YesNo

Hold Public Liability Insurance (minimum coverage $10 million) *

YesNo

Hold Professional Indemnity Insurance *

YesNo

ACTIVITY DETAILS

Please detail your proposed implementation model, including targeted priority groups, communities, frequency of clinics and anticipated vaccination numbers. *

If selected for the Primary Health Care Vaccination Grants Program for Priority Populations - Outreach Clinics, we agree to establish COVID-19 vaccination clinics for priority groups and administer COVID-19 vaccinations. *

YesNo

ACTIVITY BUDGET

Please provide a breakdown on how you intend to utilise the funds.

Expense Type *

Description of expenses *

Budgeted Amount (excl GST) *

Total Amount Budgeted $ (excl GST) *

DECLARATION

This section must be completed by an authorised representative of the organisation submitting the application.

I declare that:

I confirm the contents of this application are to the best of my knowledge accurate, complete and do not contain any false, misleading, or deceptive misrepresentation, claims or statements. *

I have read, understood, and agree to the Grant Agreement, should this application be successful. *

I declare that the organisation is financially viable and able to manage the funding within the timeframe and within budget. *

I understand that the evaluation decision is final, and no correspondence will be entered into. *

I understand and accept that information provided in this application will be stored by WNSW PHN in various formats, including hard copy and or electronic. *

I confirm that this application does not duplicate existing funding, service delivery or ongoing operational costs. *

I agree to contact WNSW PHN should I become aware of any changes to information contained in this application. *

I understand that this application does not create a legal or binding commitment. *

If the application is successful, I acknowledge that:
- The organisation will be asked to sign a Grant Agreement with the WNSW PHN;
- The organisation will be asked to sign a statement stating they have used the funds in accordance with their application;
- The organisation will provide reports to the WNSW PHN in accordance with their grant agreement; and
- The organisation agrees to maintain adequate insurance for the duration of this grant agreement and provide WNSW PHN with proof when requested. *

I understand if the conditions of the funding are not complied with:
- The WNSW PHN will recover the funds allocated; and
- The WNSW PHN may terminate the grant agreement with the applicant. *

I have read the WNSW PHN General Grant Conditions *

I have read the Grant Guidance Application *

Applicant Signature *

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Name *

Position *

Date: *

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