Organisation Address
Telephone Number
Organisation Website
Name of the most senior member of staff at the organisation
Job Title
Email Address
Telephone Number
Name of person completing this form
Job Title
Email Address
Telephone Number
Charity Number
In what year was your organisation registered as a charity?
In what year was your organisation founded?
Please give details if your organisation has merged with another charity in the past 3 years.
Number of people in your organisation:
–Full Time
–Part Time
–Volunteers
What geographic area(s) does your organisation work in?
Please describe the categories of people that benefit from your work (e.g. Elderly, Young people, Women only etc.).
Please describe the health condition(s) your organisation is concerned with (e.g. Dementia, Mental Health, Physical Abuse, Heart Disease etc.)
Please give an estimate (to the nearest €50,000) of your organisations total annual income for 2015.
What was your organisations total annual income for 2014? (to the nearest €50,000)
Please supply details of financial support in 2015 (estimated is fine):
–Government
–Local Government
–Charitable Trusts
–Companies
–Other Donations
–Fundraising Events
–Fees/earned Income
–Other (give details)
Has your organisation applied for a GSK Ireland IMPACT Award before? / Yes/No
Has your organisation ever been a Runner Up of a GSK Ireland IMPACT Award? / Yes/No
If so, please describe in detail any changes or improvements in your organisation since you applied last.
Please describe in detail, how your organisation demonstrates the below:
Innovation
Leadership, creativity and initiative in addressing current challenges in health care access and delivery.
Management
Efficient use of resources; quality of management processes; equality of opportunity; clear objectives and plans; strength and financial effectiveness of the organisation.
Partnership
Working effectively with others (members, users, voluntary, private and public sector partners etc); willingness to share ‘best practice’ and to learn from others.
Achievement
Measurable results achieved; numbers of people benefitting; impact on access to healthcare; a reflective approach to evaluation of the work; measurement and monitoring of performance, being able to report on outcomes and impact.
Community Focus
Involving and responding to users and the community; openness and provision of information; adaptability to changing circumstances and needs.
Targeting Need
Awareness of community issues and priorities; having a detailed understanding of the target community; ensuring services are accessible to and focus on people in need.
Name of Referee 1
Job Title & Organisation
Email Address
Telephone Number
Name of Referee 2
Job Title & Organisation
Email Address
Telephone Number
Please Note: Your application cannot be considered unless you also send us your most recent annual report and accounts. Please attach these to the email with your application form.
Once complete, please email your application form to:
Deadline for applications 5pm Friday 6th May 2016
2016 GSK Ireland IMPACT Awards application form1