Home IG Templates
The Templates can be viewed below in order of requirement number or by order of the template numbering used in the IG Workbook.
The templates have been developed by PSNC with the support of the Department of Health. NHS Employers, NHS Connecting for Health and the RPSGB have also contributed to the development of many of these resources. These templates have been provided as a basis for local adaptation. It is a contractor's responsibility to ensure their compliance with professional and legal requirements. Where legal advice is required, it should be sought from a Solicitor or Counsel.
If there are any resources that you believe would support efficient completion of the requirements but which are not provided below, please email info@psnc.org.uk. Likewise if you have any feedback on how the templates can be improved, please email info@psnc.org.uk.
Quick Links:
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Requirement 319 (Business Continuity) (Guidance under development)
Templates ordered by Requirement
| Requirement 114 |
Thoroughly reading the IG Workbook and the 'NHS IG: 2010/11 Update' booklet' is sufficient to meet the requirement for IG Lead training.
A template Workplan is provided as Appendix 1 of the IG Workbook or a word version can be accessed by clicking here. Alternatively the Information Governance Toolkit creates a plan based on the information input by the pharmacy.
| Requirement 115 |
Template 1: IG Policy
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
| Requirement 116 |
Template 2: Staff Confidentiality Agreement
Suggested Contract Clause for Individual Staff members: “You may not during or after the termination of your employment disclose to anyone other than in the proper course of your employment or where required by law, any information of a confidential nature relating to the company or its business or customers. Breach of this clause may lead to dismissal without notice and/or legal action. Guidance on standards expected can be found in the staff code of conduct.”
Template 13: Audit Sheet
| Requirement 117 |
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
| Requirement 119 |
This requirement has been re-numbered, for the templates, please see under requirement 304.
| Requirement 201 |
Template 3: Staff Confidentiality Code
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
| Requirement 212 |
Template 3: Staff Confidentiality Code
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
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Sample question to add to patient satisfaction survey 1. After you receive services or advice from us, we may retain some of your health information so that we’re best placed to help when you next visit the pharmacy. We always ensure this information is safely stored and kept absolutely confidential. Are you happy with our procedures or do you have any concerns? Yes/No 2a. In certain circumstances, the pharmacy may need to ask your consent to share your data with another healthcare professional to support your care. We will never pass on your health information without your express permission. Has the pharmacy ever asked for your consent like this? Yes/No 2b) If yes, do you feel your wishes were respected? Yes/No |
| Requirement 213 |
A pharmacy's existing practice leaflet should meet the Level 1 requirement
Template 5: PIL in Leaflet Format/ PIL in A4 Format (Level 2 requirement)
Template 5B: Patient Information Leaflet Large Print Version
There is a level 2 requirement that where necessary, communications materials are provided in different formats or by different routes to meet the need of patients with special or different needs. NHS Direct provide an interpreter service to support communicating with patients who do not speak English.
Template 14: Staff Signature List / Staff Signature List (Separate List)
To meet the Level 3 requirement, a question could be added to the annual Community Pharmacy Patient Questionnaire.
| Requirement 304 (was 119) |
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
Template 16: Ensuring Staff Compliance with RA01 Terms Template SOP
NB: If staff do not have cards subject to the RA01 terms and conditions (i.e. EPS Release 2 cards), this requirement can be marked not relevant (NR).
| Requirement 316 |
Template 6: Asset Register (MS Word) / Asset Register (MS Excel)
NB: The pharmacy asset register is likely to contain commercially sensitive information so there is no requirement for the details to be shared with PCTs. Where the pharmacy maintains information on software, hardware or services in a separate asset register for accounting, insurance or business continuity purposes, an option is to do a cross reference from the relevant sections in the information asset register to the relevant register or location that this information is stored to prevent duplicating effort.
| Requirement 317 |
Template 7: Physical Security Risk Assessment
| Requirement 318 |
Template 8: Mobile Computing Guidelines
Template 9: Portable equipment / Asset control form
Template 10: Disposal of Portable Assets
| Requirement 319 |
Guidance Under Development.
The Department of Health have confirmed that community pharmacies are expected to attain level 2 against each of the pharmacy information governance requirements by 31 March 2012, with the exception of requirement 9-319 (business continuity planning). This is expected to be introduced as a requirement in 2012/13.
| Requirement 320 |
Template 11: Incident Management Procedures
Template 12: Information Security Incident Report Form
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
| Requirement 321 (was requirement 305) |
Template 15: Access Control and Password Management Procedure
Template 13: Audit Sheet
| Requirement 322 (Formed from merged requirements 208 and 308) |
Template 4: Data Handling Procedure
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
Appendix 7 of the IG Workbook provides a template data map and risk register that can be completed manually. Alternatively a power point version of the template data map and a word version of the risk register can be downloaded by clicking on the links below:
Template Data Map (Power point)
Template Risk register (blank version) (Word)
Template Risk register (with worked examples) (Word)
Templates ordered by Template Numbering used in IG Workbook
Template 1: IG Policy
Template 2: Staff Confidentiality Agreement
Template 3: Staff Confidentiality Code
Template 4: Data Handling Procedure
Template 5: Patient Information Leaflet / Large Print Version / A4 Version
Template 6: Asset Register (MS Word) / Asset Register (MS Excel)
Template 7: Physical Security Risk Assessment
Template 8: Mobile Computing Guidelines
Template 9: Portable equipment / Asset control form
Template 10: Disposal of Portable Assets
Template 11: Incident Management Procedures
Template 12: Information Security Incident Report Form
Template 13: Audit Sheet
Template 14: Staff Signature List / Staff Signature List (Separate List)
Template 15: Access Control and Password Management Procedure
Template 16: Assuring Staff Compliance with RA01 Terms Template SOP
Template 17: Business Continuity Impact Document (in development)
Template 18: Business Continuity Plan (in development)
DOWNLOADS: Some documents are available in PDF format, you will require Adobe Acrobat Reader 5.0 or later for viewing which can be downloaded from the Adobe Website
DOWNLOADS: Some documents are available in ‘Microsoft Word’ format. If you do not have Microsoft Word, you can read these documents by downloading the free 'Word Viewer'. This program can be downloaded at the Microsoft website