Application to Vary Or Remove Conditions of Registration

Health Information and Quality Authority
Social Services Inspectorate
Application to vary/remove conditions of registration in accordance with section 52 of the Health Act 2007
1. Information about the centre

Centre details

/ For official use
Name of the centre
Address of the centre
Telephone number
Fax number
Email address
For official use
Centre ID:
2. Information about Applications to Vary or Remove Conditions of Registration
Type of Application
Please indication whether you wish to vary or remove a conditions of your registration: / For official use
vary conditions of registration
remove conditions of registration
Please list below the number and description of the current condition which you wish to vary/remove as per your Certificate of Registration
Please indicate below how you wish to vary the condition
When do you wish this change to come into effect? / //
Day / month / year
SupportingEvidence
Please state the reason for making the application to vary/remove the stated condition of your registration / For official use
Please provide anysupporting evidence for your application to vary/remove conditions including specific actions you are taking/propose to take to support this application to vary or remove the conditions, including:
(i)Structural changes to the premises that are used as a designated centre
(ii)Additional staff, facilities or equipment and
(iii)Changes to the management of the centre.
Please outline the steps taken to ensure that the removal or variation of the condition of registration as above will not negatively impact on residents.
Please submit details of the proposed changes to your Statement of Purpose, if applicable
3.Declaration

Declaration to be completed by applicant

I declare that, to the best of my knowledge and belief, all of the information that I have given in connection with this application is full and correct in every respect. I undertake to supply any additional information that may be required by the Chief Inspector to verify the particulars given and also to inform the Chief Inspector immediately of any alterations in these particulars. I am aware that it is an offence under the Health Act 2007 to provide false or misleading information.

For official use
Signed (by the applicant) / Sign here:
Date / //
Day / month / year
Name (please print)
Position in centre
Name of centre (please print)

Please return the completed form to:

Registration Office

Social Services Inspectorate

Health Information and Quality Authority

Unit 1301

City Gate

Mahon

Cork

Email:

RL10