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About this guide This guide is prepared by the Community Services Directorate to assist people on the Enhanced Service Offer Assessing Panel. The guide is a companion document to the Enhanced Services Offer Application Guide. These documents will provide essential information for Panel members to work through the assessment process of applications for grants under the Enhanced Service Offer. Thank you to all members for your time and expertise which are essential to this grants process.
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1. Key information for panel members .............................................................................. 5 1.1 Total time commitment for panel members ................................................................ 5 1.2 Community engagement fee ........................................................................................ 5 1.3 Transport assistance ..................................................................................................... 6 1.4 Administrative requirements ........................................................................................ 6 1.5 Location of assessment area ......................................................................................... 6 1.6 Contact point for anel members ................................................................................... 6 1.7 Conflict of Interest ........................................................................................................ 6 1.7 Essential meetings for panel members......................................................................... 7 2. Intent of the Enhanced Service Offer ............................................................................. 8 3. About the panel ............................................................................................................ 8 3.1 Responsibilities ............................................................................................................. 8 3.2 Panel membership ........................................................................................................ 9 3.3 Panel groups.................................................................................................................. 9 3.4 Experience, skills and qualifications of panel group ................................................... 10 3.5 Support for the panel .................................................................................................. 10 3.6 The role of the anel chairs .......................................................................................... 12 3.7 The role of panel pairs in consolidating scores.......................................................... 12 4. The assessment process .............................................................................................. 12 4.1 Timeframes for the assessment.................................................................................. 12 4.2 About the grants categories ....................................................................................... 13 4.3 Initial assessment ........................................................................................................ 13 4.4 How the assessment will work ................................................................................... 13 4.5 What panel members must consider.......................................................................... 14 5. Scoring against the criteria .......................................................................................... 16 5.1 Aids, Equipment and Minor Modifications ................................................................. 16 5.2 Quality of Life Grants .................................................................................................. 18 5.3 Flexible Supports and Services.................................................................................... 19 6. Documents ................................................................................................................. 21 Enhanced Service Offer ..................................................................................................... 21 Grant Panel Member ........................................................................................................ 21 Declaration ........................................................................................................................ 21 Code of conduct (Bowen Report principles) ..................................................................... 22 Confidentiality and conflict of interest agreement .......................................................... 23 Letter of offer .................................................................................................................... 25 How to Accept the Offer guide ......................................................................................... 26 Page 3 of 32
Acquittal Form .................................................................................................................. 27 Payment Advice: ............................................................................................................... 29 Treating Therapist Initial Application Support Checklist .................................................. 31
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19 August 23 August (full time) 26 August -29 August 2 September - 6 September 9 September 20 September From 23 September 23 September - mid October 2013 30 September 8 November 11 November- 15 November
18 November 22 November (full time) 25 November 29 November 2 December 6 December 9 December 20 December 2013 From January 2014 From January 2014
Each application round will require approximately five days commitment for the assessment process. Panel team members will need to be accessible to sign the panel recommendation reports.
Members of the community, who are not participating on the panel as part of their usual employment, are entitled to apply for the Community Services Directorate Community Engagement Fee. This is a small payment to support the costs associated with their participation. The Community Services Directorate Community Engagement Payment Policy sets out eligibility and the level of support to panel members.
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The application form is included in the Attachments at the end of the guide. Note this policy is being reviewed.
The Community Services Directorate will provide taxi vouchers to cover transport costs for panel members who require transport assistance to attend panel meetings. Contact the Panel Support Team on 6207 8980.
All panel members must read and/or sign the following documents as part of their role on the panel. This can be done at the Orientation Session on the first day of assessments. Confidentiality and Conflict of Interest Agreement Bowen Code of Conduct - Panel Members Declaration
For reference, these are included with the Attachments at the end of the guide.
During the assessment processes the panel will work in: The Computer Training Lab and Ballarn One meeting room Ground Floor Nature Conservation House Emu Bank, Belconnen These rooms are co-located with a lounge and kitchen area. Accessible bathrooms are in the foyer area of the ground floor.
Panel members can contact the Panel Support Team on 6207 8980.
A conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest (Lo and Field (2009) and Thompson (1993). While panel members will all sign Confidentiality and Conflict of Interest Agreement before assessment begins, they will also be asked to consider conflict of interest in relation to any application provided to them before assessment begins. This includes: a panel members potential or perceived conflict that may relate to their personal or professional knowledge of a person who has applied for a grant and
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the potential conflict afforded the person who has applied, should a panel member have access to that persons application.
Panel members will be asked to advise the panel chair if they know any person whose application is included in their portfolio for assessment. The nature and manner in which the person is known to the panel member will be considered by the chair to determine if a conflict of interest may be present. The chair will also consider whether the panel members access to a persons personal information contained in an application may represent an unreasonable intrusion into their privacy. A clinical relationship is not considered to represent a conflict of interest. A conflict of interest will be automatically declared if the panel member, in other than a clinical service delivery role: has a working relationship with a person who has applied for a grant or works in an area that has immediate contact with the person. If a conflict of interest is declared the panel member will not receive that persons application for assessment.
enable panel members to provide advice back about the process, tools, support and information provided to them to undertake their role consider ways the applications and assessment process may be improved for round two give the panel an overview of the outcome from the round ie data on successful and unsuccessful request and categories requested ensure panel members have any follow up support they need from their involvement in the process. Individual de-briefing sessions can be arranged. Members are encouraged to make use of the government Employment Assistance Program as needed.
The Enhanced Service Offer will be delivered through a grants process that is intended to: respond to priority unmet need while work is underway to prepare the ACT community for the phased introduction of DisabilityCare; through individual funding for enhanced services and supports which will improve peoples quality of life by providing respite or a respite like effect for people with disability, their families and other unpaid carers assist people with disability, their families and other unpaid carers, to be aware of DisabilityCare and to consider what it may mean for them. The ESO should provide people with an opportunity to experience choice and control over the supports and services they have in their life, to meet their needs (through the provision of grants to individuals rather than via block funding to service providers) to assist currently funded providers to consider and experience how equipped their current business models and service offers are for DisabilityCare.
The process is an opportunity to inform further work to prepare the sector to transition to DisabilityCare Australia.
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makes recommendations to the delegate about the priority of each application in the categories of: o Aids, Equipment and minor Modifications o Quality of Life grants o Flexible Supports and Services must work within the guidelines and processes outlined in the Assessing Panel Guide and the Application Guide. will make recommendations to the delegate about applications that demonstrate exceptional circumstances and combined submissions.
When making assessments, the panel will use the experience and skills of members, individually and collectively, to ensure that its decisions in assessing applications are equitable and justifiable in the public arena. With the exception of Quality of Life grants which fulfil a different purpose, the panel will only recommend reasonable and necessary supports and services consistent with each persons likely support package under DisabilityCare. The panel will alert the panel support team to people who are likely to be eligible for assistance under DisabilityCare and who are currently not supported by the formal service system so that they may be contacted and assisted. In addition the panel will identify people, for follow up by the Individual Planners who: receive core or vital supports and services from a non-recurrent source, and the person is at risk when those supports cease do not have sufficient recurrent supports and services whose informal networks are not likely to be sustained without additional formal support prior their transition to DisabilityCare have significant unmet need but are not eligible for an ESO grant, or what they require cannot be provided via an ESO grant
Membership will be determined by the ACT Government through the ACT NDIS Taskforce and with advice from relevant areas of government. Members will be selected for the broad range of experience they will bring collectively and individually to the assessment process. The panel will collectively have service delivery, policy and professional and personal experience in related areas including the provision of therapy service, aids and equipment, support services and the provision of services and supports to vulnerable people including those with psychosocial disability and Aboriginal and Torres Strait Islander peoples. The panel will include people with lived experience of disability, including psychosocial disability.
Panel members will be assigned to panel groups. Four panel members will be assigned to one of three panel groups: Aids, equipment, minor modifications Page 9 of 32
Panel members will be assigned to their group on the basis of their expertise and qualifications. Each group will have a chair and work in pairs (referred to as panel pairs) for the assessments.
should clearly outline the grounds on which the person is not eligible and be signed by the senior manager Contracts and Grants Unit. contact and assist applicants who have not completed the online application fully or correctly, or refer them to the Enhanced Service Planning team leader refer potentially vulnerable people to the Enhanced Service Planning team leader. If additional supports are established by the Individual Planners subsequent to the application being assessed, the Panel support team will ensure the persons application is updated. sort applications into groups and with panel chairs, assign a portfolio of applications to the panel pairs on the basis of members skills and expertise manage arrangements for the panel to convene. This includes ensuring each panel member has all the information they need to attend, special requirements are met, venues booking are still in place, IT is arranged, catering booked etc. set up meetings including the Orientation and Debrief; agendas set, information prepared including Community Participation fee forms, signing of Confidentially Agreements, and adjustments are made to panel members portfolios to manage to any identified or potential conflict of interest. for round two, ensure that any highly prioritised applications (unallocated) that were confirmed to be transferred to round two, are included.
During the assessing phase monitor panel progress and provide assistance including to adjust workload, to ensure the set timeframes are met provide conduit between the panel members and Individual Planners support panel participation in the process. This may include assisting with transport issues (taxi vouchers), accessibility issues, catering, community engagement payment After the assessing phase draft recommending reports with the chairs and coordinate members signatures and movement of the recommending Minute through the delegate unsuccessful letters are prepared from SmartyGrants system and for delegates signature, quality control draft Ministerial Brief on outcome of process including letters to successful for Minister ensure correspondence to people is correct and sent. This includes the preparation of all Letters of Offer and any relevant documents manage Letters of Acceptance and payment prepare Service Funding Agreement variations and advise appropriate contract manager (including from Health Directorate) of any variations monitor and manage Acquittal of Grants and return of unexpended funds monitor and prepare reports on survey monkey feedback from Enhanced Service Offer applications and service providers. Individual Planners An Individual Planning Team has been established to support the Enhanced Service Offer grants process. This team of six Individual Planners and a team manager will work to assist people with disability, including those with psychosocial disability to identify their community support needs, develop a whole of life/goal focused and strengths-based plan; Page 11 of 32
and to link to and make best use of the formal and informal supports available to in preparation for the phased introduction of DisabilityCare Australia in the ACT.
There will be three chairs to support the assessing panel to work in groups. The chairs will: be directors (senior managers will be considered depending on their experience) provide orientation to panel members on their role and responsibilities facilitate the orientation meeting facilitate the debriefing meeting facilitate the assessment process ensure consistent consideration and application of criteria ensure processes and recommendations align with ACT Government policy decisions make a final decision if two panel members are not able to agree on the priority of a particular application ensure people flagged as vulnerable or at risk, are referred to the Disability ACT Individual Planner team leader ensure all exceptional applications are referred with a recommendation, to the delegate make recommendations about the treatment of combined applications make recommendations for funding in accordance with the budget and as appropriate adjust the notional budget categories in each round to best meet with priority recommendations.
During assessment, Panel members will work in pairs. Panel pairs will: moderate their ratings discuss any rating with a discrepancy of two or more points agree and lodge a consolidated score for the applications in their portfolio (this may be an average or a consensus score). Record the rationale for their ratings Record their recommendation (for example the item/s to be funded, the need to offer follow up support or information to the person, assessment or prescription; and areas of concern and/or any caveats around their recommendations).
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Please refer to the Enhanced Service Offer Application Guide. Initial assessment is done by the panel support team before the panel meets for full assessment of all applications. This process will: check eligibility of people (ie residency , age, disability) ensure that all applications have sufficient information for further assessment categorise all applications in preparation for assessment by the panel o Aids, equipment, minor modifications o Quality of Life grants o Flexible supports and services Assign applications to the three groups for assessment and rating against criteria
Notes for panel about initial assessment If a panel member does not agree that a person is eligible they will indicate this on the application assessment form and notify the panel chair. If not enough information is provided in the application the panel support team may contact the person or their nominee and/or refer them (with their consent) to the Individual Planning team. If a person has indicated they do not receive any formal supports (other than for QOL grant applications) the panel support team will contact them or their nominee and/or refer the person (with their consent) to the Individual Planning team who can provide them with information about options, supports and services.
People who are vulnerable now The initial assessment process may also identify people who: receive core or vital supports and services from a non-recurrent source rely on informal networks that are not likely to be sustained without additional formal supports prior to their transition to DisabilityCare Australia do not have sufficient recurrent supports and services have significant unmet need but are not eligible for an ESO grant, or what they require cannot be provided via an ESO grant. In these circumstances the person will be referred by the panel chair to the Individual Planner team leader who will ensure that: the person is referred (with their consent) to any existing supports and services currently available within the service system. the person is identified for priority referral to DisabilityCare Australia.
Introduction and instructions about SmartyGrants (the grants online system) and information about the assessment process. Reading and assessing of applications will all be done online so panel members will be using SmartyGrants to complete their tasks.
The panel will have a chance to become more familiar with the assessment process and how it works by assessing a number of applications as a group. This will ensure that Panel members have a consistent understanding of the intent of each criteria and rating system and how the online system works. Panel members are assigned to one of the three panel groups. Panel members will work in pairs Panel pairs will be allocated a portfolio of applications. Panel members will review the names on applications in their portfolio of applications and declare if they have prior knowledge of a person. If the panel member has a conflict of interest, or there is potential for a conflict to be perceived in relation to a person, they should state the nature of the conflict to the panel chair and will not be involved in decision making related to that persons application. Panel members will not access information in applications where a conflict of interest has been cited.
Day 2-5 Assessing applications During the assessment process: Panel members will individually assess applications and record ratings and rationale (see section 5 scoring against the criteria) using the SmartyGrants system Panel members will meet at regular intervals with their panel pair to ensure consistency in assessment of applications Panel members complete their assessments and meet with their panel pair to consolidate their scoring of applications assigned to them Panel pairs meet with their panel chairs to review the scores against each application. Panel chairs will then make recommendations to the delegate about allocating grant funding. This is done through a summary report from the SmartyGrants system. Minute/s about recommendations to delegate will be drafted by the panel support team. The delegate will consider the panels report and recommendations to confirm grant allocations. The delegate signs off on recommendations.
When assessing applications and making recommendations, panel members must consider: consistency with DisabilityCare/NDIS principles Page 14 of 32
whether there is sufficient information to make informed and appropriate decisions around funding
Consistency with DisabilityCare/NDIS principles It is important that recommendations take into account: the persons current supports and services so that the total package is likely to be considered reasonable and necessary in the context of DisabilityCare/NDIS. For example additional respite should not be allocated as a replacement for accommodation support if that is what is actually required. Does the request seem reasonable given the age or circumstance of the person.
Reasonable and Necessary as defined under the NDIS ACT 2013 (34) Reasonable and necessary supports
For the purposes of specifying, in a statement of participant supports, the general supports that will be provided, and the reasonable and necessary supports that will be funded, the CEO must be satisfied of all of the following in relation to the funding or provision of each such support: (a) the support will assist the participant to pursue the goals, objectives and aspirations included in the participants statement of goals and aspirations; (b) the support will assist the participant to undertake activities, so as to facilitate the participants social and economic participation; (c) the support represents value for money in that the costs of the support are reasonable, relative to both the benefits achieved and the cost of alternative support; (d) the support will be, or is likely to be, effective and beneficial for the participant, having regard to current good practice; (e) the funding or provision of the support takes account of what it is reasonable to expect families, carers, informal networks and the community to provide; (f) the support is most appropriately funded or provided through the National Disability Insurance Scheme, and is not more appropriately funded or provided through other general systems of service delivery or support services offered by a person, agency or body, or systems of service delivery or support services offered:
(i) as part of a universal service obligation; or (ii) in accordance with reasonable adjustments required under a law dealing with discrimination on the basis of disability;
(g) the support is not prescribed by the National Disability Insurance Scheme rules as a support that will not be funded or provided under the National Disability Insurance Scheme; (h) the funding of the support complies with the methods or criteria (if any) prescribed by the National Disability Insurance Scheme rules for deciding the reasonable and necessary supports that will be funded under the National Disability Insurance Scheme.
Prioritised applications The following people will be prioritised above people of the same rating. People: who are not in receipt of any formal supports services who are Aboriginal or Torres Straits Islander who live with other family members with disability who live with a family member, or other unpaid carer, who is over the age of 65 who live in residential aged care. have a psychosocial disability who are parent to, and reside with children or young people under the age of 16 Page 15 of 32
Following re-priorisation as above, if the re-prioritised applications still exceed the resources available the panel may reassess prioritised applications again, against the same criterion until the panel chairs are is satisfied they can offer a justifiable suite of recommendations to the Delegate within the funds available. What is meant by people who are not in receipt of any formal support services The intent is to enable people to be prioritised over others of the same rating, if they are not currently in receipt of ongoing disability services, Home and Community Care program services or mental health services that they could reasonably be expected to eligible for through DisabilityCare. Unfunded Prioritised Applications may be transferred to Round Two The chairs will decide which, if any unsuccessful, applications should be transferred to the second round. Only people rated as being of the highest priority such as to enable a reasonable assessment to be made that the application may be likely to receive an allocation in the second round, should be transferred. Applications transferred to the second round will take the first round scoring with them.
The requested item is an effective and reasonable response to the persons needs and circumstances.
Rating 1
Aids, equipment and minor modifications criteria The criterion is not met at all The request may be assessed to have a detrimental outcome for the person The request is not be consistent with what the person would reasonably expect to receive under the NDIS (refer to Reasonable and Necessary Principle). The criterion is demonstrated in some ways or the application meets some elements of the criterion The request may limit or reduce the persons opportunities for inclusion or skill development The request may not reflect the age, stage or interests of the person. The criterion is demonstrated in some ways or the application meets some elements of the criterion There are clear benefits for the person. The criterion is well demonstrated There are clear benefits for the person There may be benefits for the persons family, unpaid carers or other informal supports and networks. The criterion is demonstrated to a very high level There are demonstrated flow on benefits for the person and their family, unpaid carers or other informal supports and networks around them The application demonstrates some element of risk* which would be addressed or substantially alleviated by the request The persons current arrangements are vulnerable to breakdown. There are demonstrated flow on benefits for the person and their family, unpaid carers or other informal supports and networks around them The criterion is met to an exceptionally high level and an exceptional level of benefit, need and priority is demonstrated The application demonstrates significant risk* factors which would be addressed or alleviated by the request The persons current arrangements are not sustainable without immediate additional supports.
*risk: to physical safety (this may include to the persons family or other unpaid supports); to health and wellbeing, of isolation or social exclusion.
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Criteria Quality of Life The criterion is not met at all The request may be assessed to have a detrimental outcome for the person. One element of the criterion is met, or the application meets some elements The item may limit or reduce the persons opportunities for inclusion or skill development The item may be reasonably available through other avenues. Some elements of the criterion are met The request may be assessed to provide some benefit to the person and their family, unpaid carers and informal networks. Most elements of the criterion are demonstrated Clear benefits are evident for the person There may be flow on benefits for the person and their family, unpaid carers and other informal supports and networks around them. All elements of the criterion are demonstrated to a very high level There are flow on benefits for the person and their family, unpaid carers and other informal supports and networks around them The request may represent a unique or innovative response to a need. All elements of the criterion are demonstrated to an exceptional level There are significant benefits for the applicant and their family, unpaid carers and other informal supports and networks around them; and The request may represent a unique or innovative response to a need.
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Rating 1
Criteria Flexible supports and services The criterion is not met at all The request may be assessed to be of limited positive outcome for a person The request would not be consistent with what the person would reasonably expect to receive under the NDIS (refer to Reasonable and Necessary Principle) The request does not reflect the persons age, life stage, interests or wishes One element of the criterion is met, or application meets some elements The item may limit or reduce the persons opportunities for inclusion or skill development. The application meets some elements of the criterion The request may be assessed to have some benefit to the person and potentially to their family and other informal supports. The application meets most elements of the criterion Clear benefits are evident for the person The request is appropriate to the age and life stage, and reflects the interests and wishes of the person There are demonstrated flow-on benefits for the person and their family and other informal supports and networks around them. All elements of the criterion are demonstrated to a very high level There are flow-on benefits for the person and their family and other informal supports and networks around them The application demonstrates some element of risk* which would be addressed or substantially alleviated by the request or The persons current arrangements are vulnerable to breakdown. All elements of the criterion are demonstrated to an exceptional level. There are significant benefits for the person and their family and other informal supports and networks around them The application demonstrates significant risk* factors which would be addressed or alleviated by the request The persons current arrangements are not sustainable without immediate additional supports.
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*risk: to physical safety (this may include to the persons family or other unpaid supports), to health and wellbeing, of isolation or social exclusion.
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6. Documents
In this section: Grants Panel Member forms and examples of documents relating to the grants
_______________ (date)
__________________________ (signature)
_______________ (date)
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The inclusion of the Code of Conduct in the PS Act in 1999 reinforced the principles underlying the Bowen Code. Source: APS Values and Code of Conduct in practice:
http://www.apsc.gov.au/values/conductguidelines.htm
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__________________________ (signature)
_______________ (date)
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Letter of offer
Name Street Suburb State Post Code Dear Re: Enhanced Service Offer Name Thank you for your application for a grant under the 2013-2014 Enhanced Service Offer. A Panel of government and community representatives has reviewed all applications and has recommended offering you the following:
Item Recommended Funding
Please find attached three documents related to this offer: A grant Acceptance Form (ESO 4) A Statement by Supplier Form An Acquittal Form (ESO 8)
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Acquittal Form
ESO Form 8
To be completed within 30 days of expenditure or no later than 12 months from the date of Offer. I, Applicants Name of Address wish to acquit the grant from Community Services Directorate for: Aids, Equipments and minor Modifications Quality of Life items Flexible Support and Services I HEREBY CERTIFY THAT: Funding of $_________was spent for the purpose specified in the Letter of Offer. I have attached documents, e.g.: receipts, as evidence of the expenditure as required. Dated this..................................day of ...............................................20__ Signed: ................................................................................ Community Organisation/Third Party Confirmation (If applicable): I HEREBY CERTIFY THAT: Funding of $_________was spent for the purpose specified in the Letter of Offer. Name: ___________________________________________________________________ Signed: ______________________________ Date: _______________________________ Position/Occupation: _______________________________________________________ Agency or Organisation:_____________________________________________________ Phone:__________________________ Email:___________________________________ Please complete this form when funds are spent, make a copy for your records and then send the originals to: Enhanced Service Offer c/o Contract and Grants Unit Community Service Directorate GPO Box 158 CANBERRA ACT 2601
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Acceptance Form
ESO Form 4
I, Name of Address wish to accept the following grant under the Enhanced Service Offer.
Recommended Allocation $ $ $ $ $ Total Grant Offer $
Item
I understand that it is my responsibility to use the funds only for this purpose, and that if I no longer require the grant I will return these funds to the Contracts and Grants Unit, ACT Community Services Directorate. I will complete the Acquittal Form (ESO Form 8) and return it to the Contracts and Grants Unit with any unspent funds and receipts as evidence of expenditure, within 30 days of expenditure or no later than 12 months from the date of Offer. ________________________________________________ Signature of the grant recipients ________________________________________________ Name (Printed) Dated this ______ (day) of __________ (month) _____________ (year) Authorisation (if not signed by the applicant) I have the authority to provide these details on behalf of the person named above. ________________________________________________ Signature of the grant recipients authorised representative ________________________________________________ Name (Printed) and relationship to the applicant Dated this ____ (day) of __________ (month) _____________ (year) Page 28 of 32
Or B. Nominate a Community Organisation (Agency) behalf. I wish to nominate an organisation to receive and manage the grant on my My preferred provider has agreed to the arrangement and has completed a Funded Support Plan (ESO Form 5).
Name of organisation and contact person Postal Address and telephone contacts
or C. Assistance to engage a Community Organisation (Agency) I wish to accept the grant and would like assistance to identify the best way for me to manage the grant. Or D. Nominate a Third Party
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I wish to nominate a Third Party to receive and manage the grant on my behalf. The third Party has agreed to this arrangement.
Third Party Name Contact Person Postal Address Telephone Contact Email Address
Document checklist to be returned to Community Service Directorate. Acceptance Form (ESO Form 4) Statement by Supplier Form Funded Support Plan (ESO Form 5), if nominating an organisation to receive the grant.
Please return all forms to: Enhanced Service Offer c/o Contracts and Grants Unit Community Services Directorate GPO Box 158 CANBERRA ACT 2601
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Treating Therapist Initial Application Support Checklist Enhanced Service Offer Applications for aids, equipment, environmental adaptations, minor modifications for Privately Owned Homes or Vehicles. This form only needs to be completed by the applicants current treating therapist and if the application is for an item which may increase the persons independence and/or reduce their reliance on paid or unpaid supports. Applicants are also able to apply for a Quality of Life Grant for items which may not have a therapeutic benefit but which may enhance the applicants quality of life. Therapist confirmation is not needed for those requests. This form will provide initial verification that the items is generally appropriate for your client to enable the assessing Panel to make an in principle recommendation. Further assessment or clinical assistance may be a requirement of funding depending on the item requested. Name of Client: Diagnosis or support need related to the requested item: Describe the Item Requested: Please tick relevant box Does the item appropriately meet the functional needs of the applicant Is the item available through ACTES/or other Government program? Will the person require further assessment before purchasing the item? If Yes, who should do this assessment/prescription? Therapy ACT Speech Pathologist, Occupational Therapist, Physiotherapist Community Aged Rehabilitation Service Speech Pathologist, Occupational Therapist, Physiotherapist Supplier: Other: What is the generally expected price range for this item: Name of Clinician: Date: Organisation: Signature: Contact Details: DETAIL YES NO DOB
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