APPLICANT INFORMATION
Prepared by:
Cleared and lodged by: Please see note below (click to enter text) PLEASE NOTE: All applications must be cleared and lodged by the highest level delegate within your organisation (e.g. THS Exec or Dep Sec).
THS Clinical Service Stream: Click to enter text	Clinical Service: Click to enter text
Email: Click to enter text	Phone number: Click to enter text
I authorise the submission of this application: By selecting a date below, you indicate authorisation through electronic submission.
Select date for electronic authorisation
APPLICATION TYPE (please select)
Amendments to service description ☐	Update existing service ☐	Add new Service or update service with significant changes ☐
Correction and update of typographical errors Amendments to service/ workforce requirements wording and/or service level descriptors	Update to one service only with no impact on other services If it is a support service level amendment, information must be provided on the impact and sustainability of other services Service and workforce requirement amendments that impact on the change of the clinical service level	A new statewide service and/or support service Changes and updates to the service that affect multiple services and/or TRDF/CSP
SERVICE CHANGE DESCRIPTION
Click to enter text
EVIDENCE BASE
Please outline: (if applicable) Reason for the Application, specifically addressing the points according to application type listed above Any funding/purchasing implications including per annum costing for additional FTE and resourcing Any workforce implications Sustainability of service level change/increase Any other relevant financial or service-related implications For a new service: short description provided on the implementation milestones and timeframes Click here to enter text
Additional information to support the Application (including relevant documentation)	Click here to enter text.

Once completed and signed, please submit this form to peter.maree@health.tas.gov.au