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AI-Application-Form-2019v3 - AI Application Form

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Country of origin: AUSTRALIA
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Page 1 of 9
NHMRC Administering Institution status
application form
Institutions applying for NHMRC Administering Institution status must complete this form
HOW TO LODGE
By email to: Research.Sector.Data.Policy@nhmrc.gov.au
Application must be sent as a PDF document.
SUBMITTING AN APPLICATION
The institution’s application contact is responsible for ensuring that the application is complete and
accurate. An incomplete application will not be assessed.
NHMRC reserves the right to ask the institution to provide additional information in support of its claims of
its suitability to administer Australian Government funding for health and medical research (e.g. laboratory
certification or procedures for management of privacy, management of concerns about research integrity,
Intellectual Property management).
RECEIPT OF APPLICATIONS
NHMRC will confirm receipt of the application by email. If institutions do not receive this email, please call
NHMRC’s Help Centre on 1800 500 983.
Institution name
Institution website URL address
Application contact name
Application contact email
Application contact phone number
Page 2 of 9
SECTION 1 – PROCEDURAL REQUIREMENTS
Details of Institution
1. What is the legal name of the institution?
2. What is the Institution’s legal entity type?
Please mark appropriate boxes:
☐ Incorporated association under Australian State/Territory legislation
☐ Incorporated co-operative incorporated under Australian State/Territory legislation
☐ Aboriginal Corporation incorporated under the Corporations (Aboriginal and Torres Strait Islander)
Act 2006
☐ Organisation established through specific Commonwealth or State/Territory legislation
☐ Company incorporated under Corporations Act 2001 (Commonwealth of Australia)
☐ Partnership
☐ Trustee on behalf of a trust
☐ Individual
☐ Australian local government body
☐ Australian State/Territory government
☐ Other (Identify below)
(Word limit: 200 words)
3. What type of organisation is the institution?
Please mark one appropriate box:
☐ University
(listed provider under Section 16-10 of the Higher Education Support Act 2003) (For
these Universities, question 4 not required; please continue with question 5)
☐ University (not a listed provider under the Higher Education Support Act 2003)
☐ Other Health and Medical Research Institutions – Medical Research Institutes
☐ Other Health and Medical Research Institutions – Non-government hospitals
☐ Government Department – Hospital or area health service
☐ Government Department –- Other
Other (describe)
4. Please provide the address of any facilities in Australia where the institution conducts research
(If you selected the first tick box under question 3, question 4 is not required; please continue with
question 5)
(Word limit: 200 words)
(Word limit: 200 words)
Page 3 of 9
5. What is the number of full time equivalent staff?
☐ 1-
4
☐ 4-20
☐ 21-100
☐ 101-200
☐ 200+
Financial Details
6. What is the institution’s Australian Business Number (ABN) and/or an Australian Company Number
(ACN)?
ABN:
ACN:
7. What is the institution’s Indigenous Corporation Number (ICN), if applicable?
Only answer this question if your organisation is a registered Indigenous corporation. If not applicable,
please type ‘N/A’
(Word limit: 200 Words)
8. Is the institution registered for GST?
☐ Yes
☐ No
9. Is the institution a government related entity?
☐ Yes – please provide details below
☐ No
(Word limit: 200 words)
10. Is the institution affiliated with a consortium or peak body?
☐ Yes – please provide details below
☐ No
(Word limit: 200 words)
Page 4 of 9
11. What is the institution’s Australian bank account?
Provide details of the nominated Australian bank account for receipt of NHMRC grant payments
BSB Number:
Bank Account Number:
Bank Name:
Bank Account Name:
12. Is the institution registered with the Australian Charities and Not-for-profits Commission?
☐ Yes
☐ No
13. Does your institution have a Recipient Created Tax Invoice Agreement (RCTI)?
☐ Yes (Supply below)
☐ No
Vendor Number: (Insert if known)
Note: The Vendor Number can be located via your organisation’s Commonwealth Department of Health RCTI.
14. Please provide the URL for the most recent annual report
(Word limit: 200 words)
Contact Information
15. What is the institution’s main physical address? (i.e. the physical address of the Chief Executive’s
office/Vice-Chancellor/equivalent)
Building/Floor
Business Address line 1
Business Address line 2
Suburb/Town
State/Territory
Postcode
16. What is the institution’s main postal address?
Building/Floor
Business Address line 1
Business Address line 2
Suburb/Town
State/Territory
Postcode
Page 5 of 9
17. Primary Contacts
Primary Research Administration Officer (RAO) contact
The following person/s are authorised to be contacted regarding the information provided in this application form and
funding information if the institution receives Administering Institution status.
Secondary RAO contact
Primary Responsible Officer (RO) contact
The following person/s are authorised to execute grant schedules on behalf of the institution.
Page 6 of 9
17. Primary Contacts (Cont.)
Secondary RO contact
Finance Officer (FO) contact
Please provide details of the Finance Officer/person (FO) authorised to be contacted if Administering Institution status is
given, regarding grant financial information such as financial reporting.
Chief Finance Officer (CFO) contact
Please
provide details of the Chief Finance Officer/person (CFO) authorised to approve grant financial information if
Administering Institution status is given, for financial information such as financial reporting.
Privacy Notice
NHMRC is collecting personal i
nformation in this form in relation to your Institution’s contact officers. This personal
information
is used by NHMRC for the purpose of your Institution’s application for NHMRC Administering Institution status.
It may also be used by NHMRC if you are successful, in relation to future NHMRC funding.
Please note that if your Institution is given NHMRC Administering Institution status, certain of your Institution’s staff
members/researchers may be given access to the NHMRC Research Grants Management System (RGMS).
Their personal information will be collected and stored in RGMS for the purpose of NHMRC funding. Separate Privacy notices
are provided and consents are required, as set out through their individual access to RGMS.
Further information can be found in NHMRC’s Privacy Policy (nhmrc.gov.au/nhmrc-privacy-policy).
For a copy, please contact the NHMRC Help Centre at help@nhmrc.gov.au.
Page 7 of 9
SECTION 2 – USE AND DISCLOSURE OF INFORMATION
NHMRC is committed to protecting privacy in accordance with the Privacy Act 1988 (Privacy Act). Further
information about NHMRC's collection, use and disclosure policies in relation to personal information, how to
access or correct personal information, and how to submit a complaint to NHMRC about a breach of privacy
is set out in NHMRC's Privacy Policy.
NHMRC considers that where information (including personal information) provided in this application is
collected and combined with information that is required at grant submission, the combined information may
be used for the following purposes:
a) to comply with the Australian Government requirement to publish the names of all grant recipients on
the Agency’s websites (nhmrc.gov.au) as well as GrantConnect (grants.gov.au),
b) to inform staff negotiating and establishing grant agreements of risks and issues which need to be
addressed in the grant agreement for that program, and/or
c) to inform future assessments for applications including during peer review.
The signature of the authorised representative of the institution in section 4 acknowledges and agrees that
the information in this form and grant applications and reports may be used by the Australian Government
for the purposes listed in a), b) and c) above.
SECTION 3 – PRIMARY RAO CONSENT TO DISCLOSE CONTACT INFORMATION
NHMRC may provide contact information to other government agencies and Federal Parliamentarians as
required relating to grant announcements and other grant reporting.
I, the Primary RAO for __________________________ agree for my contact information to be used by
NHMRC for the purposes listed above.
Signature: (Physical/electronic)
Name: (BLOCK LETTERS)
Position in Institution:
Date:
Page 8 of 9
SECTION 4 – DECLARATION
Guidance for completing this declaration
This declaration must be signed by an authorised representative of the institution. The authorised
representative should be a person who is legally empowered to enter into contracts and commitments on
behalf of the institution.
An application which does not provide all required information or which contains false or misleading
information may be excluded from consideration.
I am authorised to seek NHMRC Administering Institution status on behalf of my Institution.
I declare that, at all times, the institution is willing and able to:
• enter into the NHMRC Funding Agreement;
• comply with relevant NHMRC policies and guidelines, and
• report on compliance when required.
In order to administer NHMRC funds, I declare that the institution complies with the following:
The institution
• engages in health and medical research as one of the institution’s main objectives
• has
a physical location in Australia where it conducts research
• has an independent governing board or council with scientific and administrative experience, skills and
qualifications
• will ensure contact information for the institution is provided and updated regularly
• has adequate facilities and equipment for research
• has the capacity to cover indirect costs of research
Legal
• is a legal entity, able to enter into legally binding agreements
Financial
• is not bankrupt or subject to insolvency proceedings and is financially solvent, and has systems in place
that ensure that it will remain solvent
• has
an Australian Business Number (ABN) or Australian Company Number (ACN)
• has
an Australian bank account
• has sufficient and available resources for the administration and acquittal of Commonwealth funds in
accordance with the NHMRC Funding Agreement
Insurance
• maintains at all times Certificates of Currency for Public Liability insurance to a minimum $10 million in
respect of any claim or series of related claims, Professional Indemnity insurance to a minimum $10 million
in respect of any claim or series of related claims and Worker’s Compensation insurance for all employees
and sub-contractors involved in delivery of the services
Governance
• has the capacity to undertake any research activities for which it receives NHMRC funding, including staff
with the appropriate experience, skills, qualifications and time available to commit to the activities
• has a mechanism for planning, monitoring, evaluating and managing the achievement of research aims
(e.g. a formal performance review scheme) as an institution
• has a governance and management structure in place that has:
– formal reporting lines and responsibilities
Page 9 of 9
– a current risk management plan
– an annual report published on its website each year
– the capacity to establish formal agreements with participating institutions
– the capacity to comply with the requirements of the Australian Code for the Responsible Conduct of
Research and NHMRC’s requirements for notification of research integrity matters
– clear intellectual property arrangements
Policies and Procedures
• has policies, procedures and training, staffing and infrastructure in place to:
– enable the employment of Chief Investigators (CIs) named on research grants funded by NHMRC
– ensure that the institution maintains a high standard of research integrity and ethical governance
– meet NHMRC’s gender equality requirements, which include supporting the progression and retention of
women in health and medical research
– ensure the identification, declaration, management, and reporting to NHMRC of any Conflicts of Interest
– support research environments that are free from bias, discrimination and sexual or other harassment
and have procedures in place to fairly address any instances of such behaviour
– ensure that researchers comply with the requirements in the NHMRC Funding Agreement, including but
not limited to:
» the conduct of research in an ethical, responsible, diligent and competent manner
» compliance with all applicable NHMRC approved standards and guidelines
– ensure that reports are submitted to NHMRC by appropriate personnel by specified due dates ensure
that NHMRC has access at all times to financial records associated with any funding provided to the
organisation by NHMRC
– ensure that all Administering Institution records for nominated contact staff are up to date
– have systems and management processes in place to ensure any officer of the organisation is not
involved in any activities involving dishonesty including potential misappropriation of monies
Legislation
• complies with all relevant Commonwealth and State legislation.
I certify that the information given in this application is complete and correct.
Signature: (Physical/electronic)
Name: (BLOCK LETTERS)
Position in Institution:
Date:
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Completed 3 July 2020

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