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Name of organisation: *

Legal status (include Companies Office and/or Charities Commission registration number if known): *

Contact person: *

Role: *

Email: *

Phone: *

Primary physical address: *

Number of staff (full time & part time): *

Number of personal computers (includes laptops and desktops) - Should be 20 or less: *

Approximate income last financial year ($): *

A link to your website (if it exists):

Which of the following critical social services groups does your organisation contribute to?

Please select all relevant groups: *

family violence

child abuse and neglect

budget and financial advice

sexual violence

early intervention for vulnerable and at-risk children and families

families under stress

vulnerable and at-risk young people

vulnerable and at-risk older people

Other

Which vulnerable population groups does your organisation’s service(s) contribute to?

Please select all relevant population groups: *

Children and youth

Older people

Disabled people

Single parents with dependants

People with pre-existing/concurrent psychiatric illness

People who have experienced previous traumatic events or stress (e.g. family violence victims)

Lower socioeconomic status

Maori

Pacifica

Refugees and migrants

People with housing related needs

People under financial stress

People living in worst hit areas

Those who have already been significantly affected by the Canterbury earthquakes

Those who have experienced significant injuries

Family/friends/colleagues of those who have died

Is your organisation financially viable and prepared to invest in ICT and to improve your efficiency and effectiveness: *

Yes

Are you willing to collaborate and share your ICT experience with other NGOs?: *

Yes

We recommend that you discuss your intended participation in this project with one or more of your Board members to gain their support and commitment to helping to implement any recommendations.

Have you discussed your intended participation in this project with one or more of your board members?: *

Yes

Is there a commitment to considering and/or implementing the recommended ICT improvements identified in your ICT plan?: *

Yes

What two things do you most want to address as a result of participating in this project? Describe – e.g. recommendations as to how the organisation can make better use of ICT, advice to fix a specific ICT problem, better store client information, etc: *

Who currently provides your ICT support services

Please select all that are applicable: *

Volunteers

Staff

An external provider

If there is any other information that you wish to share with us ?:

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