Standard Templates / Forms

The following Templates / Forms are available for download.

 
Comments Log This log can be completed and returned to bsu.nonstatagencies@hse.ie should anyone wish to comment on any aspect of the Governance Framework.

Governance Self-Evaluation Questionnaire

This questionnaire provides an overview of a broad range of governance issues relating to a proposed service and provides the organisation with a tool to assess the adequacy of it's governance structures and processes.

Employment Monitoring Template suggested for Schedule 9

This template is for use in Disability Arrangements in completing Schedule 9. It is suggested best practice for other Care Groups.
Supplementary Information Staffing Template This is an Excel template used to capture detailed staffing information relevant to a proposed service.

2018 Schedule 9 Template Senior Staff Remuneration Details (Revised Oct 2017)

This template is a national standard template for collation of senior staff remuneration details as required in Schedule 9 (For use in Non-Disability Arrangements). For Disability Arrangements the senior staff remuneration template is incorporated into a composite Disability template suite (see below).

2018 Schedules 3, 9 and KPI's Disability Composite Template (Section 38/Section 39)

This is a national standard template for use within the Disability sector. It is used to capture a data for service specification in all voluntary agencies funded by the Health Service Executive.

2018 Schedule 3 Template - Basic Input Sheet for Service Specification Quantum   - Non-Disability Section 38/Section 39 (Unchanged from 2015)

This template is for use in all other Care Groups (Excl. Disabilities) where the activity information required for Schedule 3 would benefit from an excel format.

2018 Schedules, 3, 9 and KPI's Disability Composite Template (For Profit Agencies)

This is a national standard template for use within the Disability sector. It is used to capture data for service specification in For-Profit/Commercial agencies funded by the Health Service Executive.

2018 Schedule 3 Template - Basis Input Sheet for Service Specification Quantum - Non Disability For Profit Agencies (Unchanged from 2015)

This is a national standard template for use with agencies providing non-Disability services . It is used to capture data for service specification in For-Profit/Commercial agencies funded by the Health Service Executive.

Clarifications Document Disability Composite Template 2017

Guide to Disability Schedule 3 Service Specification Template

 

Chairperson's Statement (SAMPLE)

Under the Grant Aid Agreement organisations are required to return a Chairperson's Statement to the HSE.  Where organisations to not have an internal format for this they should use this standard proforma document.  Organisations should ensure the elements covered in this proforma are covered in any internal reports submitted.