Local Backup Procedures - the Royal Cornwall Hospitals Trust ...

Title: 

Document author: 

Document type: 

Document library section: 

Sub Section: 

Document status: 

Approved by: 

Can this document be published to the 

internet (publicly available) 

Brief summary of document 

Document reference code: 

Local Backup Procedures 

IT Security Manager 

Governance 

Final 

Information Governance sub-committee 

Not necessary as an internal document 

These Procedures outline the actions and responsibilities 

for performing Backups of information for servers not 

contained within the Cornwall NHS corporate resilient 

architecture. 

Server Back Up Tape Procedure – Local/Satellite Sites 

This document replaces (exact title of 

previous document or NA) 

Approved Equality Impact Assessment Yes 

attached 

Cross referenced to: The Data Protection Act 1998 

Confidentiality: NHS Code of Practice 

BS ISO/IEC 27001 Information Security 

Caldicott Guardian Manual 2006 

Records Management: NHS Code of Practice 

NHS Information Governance 

Information Security Management: NHS Code of Practice 

The Data Protection (Processing of Sensitive Personal 

Data) Order 2000. 

The Computer Misuse Act (1990) 

Regulation of Investigatory Powers Act 2000 

Health & Social Care Act 2001 

Civil Contingencies Act 2004 

Ratified by: 

Integrated Governance Committee 

Date of ratification 26 September 2012 

Name of Executive signing policy Robert Knibbs, Director of Finance and Performance 

Review date March 2015 

Suggested key words (to be completed 

by Governance Administrator) 

Expired documents should be retained 

for 10 years from the date of expiry 

Version control table 

Date Version number Summary of changes Changes made by 

This document should not be photocopied or otherwise reproduced. 

If you have any questions about this policy, please contact the Governance Administrator, Telephone 

01726 627811, or via email to Policies.PCT@Cornwall.nhs.uk 

This document is available in other formats such as large print, Braille &/or 

cassette/CD or in any other 

Version: 1.0 Page 1 of 16 

Author: Andrew Mann Local Backup Procedure 

Updated: Jul 2012 

Reviewer: Trust IGC’s 

Review Due: Jul 2015

Page 2 

Consultation 

List the individuals (use titles only)/groups 

consulted. This must include the Counter Fraud 

Local Security Management Specialist 

Director of Finance/SIRO 

Head of Information Governance 

Head of Corporate Compliance 

Caldicott Guardian 

IG/IT Security Manager 

Corporate Risk Manager 

Freedom of Information Manager 

Operational Records Manager 

Deputy Director of CITS 

Associate Director of Corporate Information 

Company Secretary 

Counter Fraud Local Security Management Specialist 

Information Governance 

Sub Committee 

Indicate which of the 

consultees in the left 

hand column have 

responded 

Yes 

Yes 

Yes 

Consultation comments 

received 

Change to review date 

Minor formatting changes 

Comments 

Accepted 

Comments 

rejected 

Reason for 

rejection 

Disseminate to: 

All Staff 

Dissemination methods: 

Publish on intranet, document library administator. 

Notify staff of publication by Weekly Staff Bulletin. 

Copy to displayed within the safe storing the backup tapes – for reference. 

Aim: 

Backups are an important part of IT Business Continuity and Disaster Recovery. This 

procedure documents the actions and responsibilities for staff to ensure that 

information is secured, enabling it to be restored at a future time following an incident 

resulting in data loss. 

Purpose: 

The purpose of this Local Backup Procedure is to preserve: 






Availability That information systems are available for use as defined within the service 

level agreement for each system. 

Reliability That information systems have appropriate measures in place to ensure 

reliability through backup and recovery procedures to support disaster recovery and 

business continuity plans. 

Responsibility That staff and contractors are aware of their responsibilities for the 

protection and security of information. 

Objectives: List the objectives to be achieved. They must be Specific, 

Measurable, Realistic and Timebound (SMART) 

Responsibilities: 

Contained in Procedure 

Definitions/Glossary: 

Introduction: 

Text of document (remember to refer to organisational format requirements) 

Training: Has a training need been identified? If so what is it and how will it be 

addressed 

Training will be provided by Cornwall IT Services initially and then will flow out to staff 

as needed. 

Key Performance Indicators: List how you, as the policy author, will measure the 

success of achievement against the objectives 

Assessment against the Information Governance Toolkit and annual submission of 

scoring against this. Internal audit will review evidence gathered and report. 

Monitoring: To which Board/sub-committee/committee will the results of the 

outcome of the assessment against the key performance indicators be reported 

Information Governance Sub Committee 

Integrated Governance Committee 

Equality Impact Assessment: Attach a completed EIA prior to submitting for 

approval/ratification 







1 Purpose 

The document describes a procedure for the systematic changing of server 

backup tapes. 

2 Responsibility 

It is the responsibility of staff who are tasked with the changing of server 

backup tapes to ensure compliance with this procedure. It is the 

responsibility of Property Managers/Information Asset Owners for each of 

the servers to ensure the implementation of this procedure. 

3 Definitions 

Servers are in place at several trust locations and contain the information 

stored or saved within the IT network at each location. The information is 

backed up onto tapes to ensure availability in the event of disruption to the 

network. 

4 Training Implications 

Staff are already responsible for changing server tapes but will need to 

comply with this procedure in the future. 

5 This Policy/Guidance/Strategy/Protocol is cross referenced to: 

The Data Protection Act 1998 

The Freedom of Information Act 2000 

The Human Rights Act 

Confidentiality: NHS Code of Practice 

BS ISO/IEC 27001 Information Security 

Caldicott Guardian Manual 2006 

Records Management: NHS Code of Practice 

NHS Information Governance 

Information Security Management: NHS Code of Practice 

The Data Protection (Processing of Sensitive Personal Data) Order 2000. 

The Copyright, Designs and Patents Act (1988) 

The Computer Misuse Act (1990) 

The Health and Safety at Work Act (1974) 






Human Rights Act (1998) 

Regulation of Investigatory Powers Act 2000 

Health & Social Care Act 2001 

Civil Contingencies Act 2004 

Related Trust Policies 

Information Governance Policy and Strategy 

Records Management Policy and Strategy 

Information Risk Management Policy 

Security Policy 

Disciplinary Policy 

Data Protection Policy 

IT Security Policy 

Mobile Data Security Policy 

Email and Internet Policy 

Safe Haven Policy 

Network Security Policy 

Confidential Waste Policy 

Forensic Readiness Policy 

System Security Policies 

Freedom of Information Policy 

Mobile IT Security Policy 

IM&T Acceptable Use Policy 

IM&T Disposal Policy 

Information Security Policy 

Business Continuity Plans 

Information Quality Policy 

Data Quality Policy 

6 Equality and Diversity Impact Assessment taken place: Yes 

7 Training Implications 

For cascading to staff responsible for changing backup tapes. 

8 Who this document is relevant to: 

This document is relevant to staff who change server tapes in trust 

locations, Property Managers, Information Asset Owners and staff 

responsible for business continuity plans. 

9 Process for monitoring compliance and effectiveness 

This procedure will be implemented, managed and monitored by the 

Information Asset Owners who will provide assurances to the Senior 

Information Risk Owner. Risk assessment of servers will be completed by 

CITS who will also provide backup tape validation assurance. Business 

Continuity plans should include review of this procedure. 







There are two distinct types of backups: 

1. Corporate backups – Part of the resilient infrastructure for critical 

applications 

2. Local backups – other locations that have a locally based server. These 

are mainly file and print servers, but some do run applications locally. 

These procedures and controls relate to servers that are not part of the 

corporate resilient solution for critical applications and for the purposes of this 

procedure will be referred to as ‘local’ servers. 

Server room Controls 

All server rooms should be compliant with standard controls as specified in the 

Server Controls Framework and risk assessed accordingly. The server controls 

framework covers areas such as: 

• Physical Access 

o Building security 

o Room Security 

• Electronic Access 

o Firewalls 

o Networks 

o Login 

o Encryption 

• Environmental Control 

o Fire 

o Heat 

o Flood 

o Leaks 

o Power supply 

A risk assessment has been undertaken for all server rooms and the 

assessment is based on the adequacy of these controls at each location, a copy 

of the assessment can be obtained by contacting IT Security or the Trust IG 

Lead. 

Tape Security 

The following method ensures that the server data is protected by a good range 

of backup tapes that will allow data to be recovered from any given period in the 

last 3 months. 

• All backup tapes must be kept physically safe in a fire-proof safe so that 

they can be recovered in the event of disaster. 

• Each site should also use cleaning tapes to clean the backup drive as 

and when prompted by the system, Cornwall IT Services or according to 

the manufacturer’s instructions. 

• Each site should identify at least two people, to allow for absences, who 

are responsible for changing backup tapes and reporting any problems. 






• Any problems or risks identified with the backup tape procedure must be 

reported in the first instance to the Information Asset Owner and CITS, 

who will instigate the business continuity plan to ensure back up of 

information and data. Server business continuity plans are held by CITS. 

Back up Cycle 

A standard Daily/Weekly/Monthly cycle is to be used based on a 12 week or 12 

month schedule. 

12 Week: 

• 4 Daily tapes used every Monday – Thursday. 

• 4 Weekly Tapes used every Friday except the last Friday of the month. 

• 3 Monthly Tapes to be used on the last Friday of every month. 

12 Month: 

• 4 Daily tapes used every Monday – Thursday. 

• 4 Weekly Tapes used every Friday except the last Friday of the month. 

• 12 Monthly Tapes to be used on the last Friday of every month; 

JAN,FEB, MAR etc. 

Please see Appendix 2 and Appendix 3 for schedule details. 

Every time a tape is removed from the computer after a backup, the backup log 

(Appendix 1) must be updated. This will enable the life span of the tape and 

tape unit to be monitored. 

Tape Replacement 

Tapes are mechanical in nature and don’t have a lifespan measured in time but 

rather in terms of the number of times the tape is used. Therefore it is 

recommended that; Monday-Thursday Tapes should be replaced annually, 

Friday and Monthly Tapes should be replaced every 5 years. 

Cornwall IT Services check the backup logs for all servers on a daily basis and 

investigate any recorded messages. In the event of an identified tape failure 

the tape will need to be replaced immediately. If two or more tapes fail from the 

same batch within a month cycle then the whole batch should be replaced. 

However, when loading tapes, any issues identified need to be reported to CITS 

immediately. 

All tapes that have been replaced need to be physically destroyed. Contact 

CITS Service Desk to arrange for collection and disposal in line with the Policy 

for the safe disposal of IM&T equipment and electronic media. 






Daily Tape Log 

Appendix 1 

Date Tape ID Signed Name Notes 






12 Week Retention Schedule: 





Review Due: Jul 2015 

Appendix 2 

20 

12 M T W T F M T W T F M T W T F M T W T F M T W T F 

JA 

N 2 3 4 5 6 9 

1 

0 

1 

1 

1 

2 

1 

3 

1 

6 

1 

7 

1 

8 

1 

9 

2 

0 

2 

3 

2 

4 

2 

5 

2 

6 

2 

7 

3 

0 

3 

1 

FE 

B 1 2 3 6 7 8 9 

1 

0 

1 

3 

1 

4 

1 

5 

1 

6 

1 

7 

2 

0 

2 

1 

2 

2 

2 

3 

2 

4 

2 

7 

2 

8 

2 

9 

MA 

R 1 2 5 6 7 8 9 

1 

2 

1 

3 

1 

4 

1 

5 

1 

6 

1 

9 

2 

0 

2 

1 

2 

2 

2 

3 

2 

6 

2 

7 

2 

8 

2 

9 

3 

0 

AP 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 

R 2 3 4 5 6 9 0 1 2 3 6 7 8 9 0 3 4 5 6 7 0 

MA 

Y 1 2 3 4 7 8 9 

1 

0 

1 

1 

1 

4 

1 

5 

1 

6 

1 

7 

1 

8 

2 

1 

2 

2 

2 

3 

2 

4 

2 

5 

2 

8 

2 

9 

3 

0 

3 

1 

JU 

N 1 4 5 6 7 8 

1 

1 

1 

2 

1 

3 

1 

4 

1 

5 

1 

8 

1 

9 

2 

0 

2 

1 

2 

2 

2 

5 

2 

6 

2 

7 

2 

8 

2 

9 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 3 

JUL 2 3 4 5 6 9 0 1 2 3 6 7 8 9 0 3 4 5 6 7 0 1 

AU 

G 1 2 3 6 7 8 9 

1 

0 

1 

3 

1 

4 

1 

5 

1 

6 

1 

7 

2 

0 

2 

1 

2 

2 

2 

3 

2 

4 

2 

7 

2 

8 

2 

9 

3 

0 

3 

1 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 

SEP 3 4 5 6 7 0 1 2 3 4 7 8 9 0 1 4 5 6 7 8 

OC 

T 1 2 3 4 5 8 9 

1 

0 

1 

1 

1 

2 

1 

5 

1 

6 

1 

7 

1 

8 

1 

9 

2 

2 

2 

3 

2 

4 

2 

5 

2 

6 

2 

9 

3 

0 

3 

1 

NO 

V 1 2 5 6 7 8 9 

1 

2 

1 

3 

1 

4 

1 

5 

1 

6 

1 

9 

2 

0 

2 

1 

2 

2 

2 

3 

2 

6 

2 

7 

2 

8 

2 

9 

3 

0 

DE 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 

C 3 4 5 6 7 0 1 2 3 4 7 8 9 0 1 4 5 6 7 8 1 

Ke 

y: 

Annual Tape Usage: 

DAILY (MON-THU 

TAPE) MONTH 1 Total Tapes Used: 11 

FRIDAY 

1 MONTH 2 

FRIDAY 

2 MONTH 3 

FRIDAY 

3 

FRIDAY 4 ( Only for months with 5 Fridays) 

Mon 53 Fri 1 12 Month 1 4 

Tues 52 Fri 2 12 Month 2 4 

Wed 52 Fri 3 12 Month 3 4 

Thurs 52 Fri 4 4

12 Month Retention Schedule: 

Appendix 3 

20 

12 M T W T F M T W T F M T W T F M T W T F M T W T F 

JA 

N 2 3 4 5 6 9 

1 

0 

1 

1 

1 

2 

1 

3 

1 

6 

1 

7 

1 

8 

1 

9 

2 

0 

2 

3 

2 

4 

2 

5 

2 

6 

2 

7 

3 

0 

3 

1 

FE 

B 1 2 3 6 7 8 9 

1 

0 

1 

3 

1 

4 

1 

5 

1 

6 

1 

7 

2 

0 

2 

1 

2 

2 

2 

3 

2 

4 

2 

7 

2 

8 

2 

9 

MA 

R 1 2 5 6 7 8 9 

1 

2 

1 

3 

1 

4 

1 

5 

1 

6 

1 

9 

2 

0 

2 

1 

2 

2 

2 

3 

2 

6 

2 

7 

2 

8 

2 

9 

3 

0 

AP 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 

R 2 3 4 5 6 9 0 1 2 3 6 7 8 9 0 3 4 5 6 7 0 

MA 

Y 1 2 3 4 7 8 9 

1 

0 

1 

1 

1 

4 

1 

5 

1 

6 

1 

7 

1 

8 

2 

1 

2 

2 

2 

3 

2 

4 

2 

5 

2 

8 

2 

9 

3 

0 

3 

1 

JU 

N 1 4 5 6 7 8 

1 

1 

1 

2 

1 

3 

1 

4 

1 

5 

1 

8 

1 

9 

2 

0 

2 

1 

2 

2 

2 

5 

2 

6 

2 

7 

2 

8 

2 

9 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 3 

JUL 2 3 4 5 6 9 0 1 2 3 6 7 8 9 0 3 4 5 6 7 0 1 

AU 

G 1 2 3 6 7 8 9 

1 

0 

1 

3 

1 

4 

1 

5 

1 

6 

1 

7 

2 

0 

2 

1 

2 

2 

2 

3 

2 

4 

2 

7 

2 

8 

2 

9 

3 

0 

3 

1 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 

SEP 3 4 5 6 7 0 1 2 3 4 7 8 9 0 1 4 5 6 7 8 

OC 

T 1 2 3 4 5 8 9 

1 

0 

1 

1 

1 

2 

1 

5 

1 

6 

1 

7 

1 

8 

1 

9 

2 

2 

2 

3 

2 

4 

2 

5 

2 

6 

2 

9 

3 

0 

3 

1 

NO 

V 1 2 5 6 7 8 9 

1 

2 

1 

3 

1 

4 

1 

5 

1 

6 

1 

9 

2 

0 

2 

1 

2 

2 

2 

3 

2 

6 

2 

7 

2 

8 

2 

9 

3 

0 

DE 

1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 

C 3 4 5 6 7 0 1 2 3 4 7 8 9 0 1 4 5 6 7 8 1 

Ke 

y: 

DAILY (MON-THU 

TAPE) 

WEEK 1 MONTH END TAPE Total Tapes Used: 20 

WEEK 2 

(Labelled JAN, FEB, MAR, etc.) 

WEEK 3 

WEEK 4 ( Only For Months With 5 Fridays) 

Annual Tape Usage: 

Mon 53 Fri 1 12 

Tues 52 Fri 2 12 

Wed 52 Fri 3 12 

Thurs 52 Fri 4 4 






Section Governance Officer responsible for the 

Andrew Mann, IT Security Manager – IG (CITS) 

assessment 

Name of Policy to 

be assessed 

Server Backup Tape Procedure – 

Local/Satellite Sites 

Date of 

Assessment 18/09/12 

Is this a new or existing 

Policy? 

New 

1. Briefly describe the aims, objectives and 

purpose of the Policy. 

Backups are an important part of IT Business Continuity and Disaster Recovery. This 

procedure documents the actions and responsibilities for staff to ensure that 

information is secured, enabling it to be restored at a future time following an incident 

2. Are there any associated objectives of 

the Policy? Please explain. 

3. Who is intended to benefit from this 

Policy, and in what way? 

4. What outcomes are wanted from this 

Policy? 

5. What factors/forces could 

contribute/detract from the outcomes? 

6. Who are the main 

stakeholders in relation to 

the Policy? 





Review Due: Jul 2015 

resulting in data loss. 

To assign responsibilities of tape backups. To provide a tape rotation to ensure that 

information can be restored back to a suitable point in time. Tapes are stored 

securely. 

The organisation with benefit as this forms part of services Business Continuity and 

Disaster Recovery procedures. Patients will benefit ultimately from the provision and 

availability of high quality information and data which meets the Data Protection Act, 

Freedom of Information Act, Human Rights Act, IT Security: NHS Code of Practice 

and Records Management: NHS Code of Practice. 

That the information processed by the trust, in all formats, is protected to the highest 

possible standards and available quickly, processed in line with legislation and all 

confidentiality requirements, Government standards and Connecting for Health 

requirements. 

All staff responsible for changing backup tapes as well as site managers should be 

aware of the backup requirements and tape rotation. All service managers should be 

aware of the backup cycles and therefore the period of time that information can be 

restored back to. 

Trust Board in meeting its responsibilities. 

Information Governance Sub Committee 

and Head of Information Governance as 

the key operating functions responsible for 

implementing information governance 

throughout CIOSPCT. IT Security 

7. Who implements the Policy, 

and who is responsible for the 

Policy? 

Information Governance 

Sub Committee - Site 

Managers are 

responsible for ensuring 

that appropriate 

procedures are in place

8. Are there concerns that the Policy could 

have a differential impact on RACIAL 

groups? 

Managers and the Server Team (in 

Technical Services) are responsible for 

ensuring the procedures are practical and 

meet requirements. 

No 

to protect continuity of 

services. 

This Procedure reflects the current national guidance and best practice 

and is designed to protect the rights of all, irrespective of racial groups. 

The standards of IG, documents referenced in this Procedure and 

training will take account of the need to protect data in any required 

format or language to ensure accessibility to all to ensure correct use and 

handling. 

What existing evidence (either presumed or 

otherwise) do you have for this? 

A requirement of the information governance programme specifically relates to the 

provision of information in differing formats and evidence is collated to support this. 


This Procedure reflects the current national guidance and best practice 

have a differential impact due to GENDER No and is designed to protect the rights of all, irrespective of gender. 



There are no sections within this Procedure that distinguish between gender or 

transgender. 


have a differential impact due to 

DISABILITY? 



Yes 

The Procedures rely on a colour coded matrix to identify the correct tape 

for the different days of the week and end of month. Should a disabled 

person be appointed who has the responsibility for undertaking these 

duties, then the legal obligation to make reasonable adjustments to 

enable them to adequately and competently perform their duties will be 

made. 


have a differential impact due to SEXUAL 

ORIENTATION? 

No 

There are no sections within this Procedure that would be impacted by 

sexual orientation. 









have a differential impact due to their AGE? No 

Age is not relevant to the subject of this Procedure. 



This Procedure and its content and implementation will not be impacted by age of 

staff or patients. 


have a differential impact due to their 

RELIGIOUS BELIEF? 

No 

Religious beliefs are not relevant to the subject of this Procedure 



No references to Religious beliefs are made within this Procedure. 

14. Are there concerns that the policy could 

have a differential impact due to their 

MARRIAGE OR CIVL PARTNERSHIP 

STATUS? (This MUST be considered for 

employment policies). 

No 

Marriage nor civil partnership are relevant to this Procedure. 



There are no sections in this Procedure that are relevant to partnerships of any kind. 


have a differential impact due to GENDER 

REASSIGNMENT OR TRANSGENDER 

ISSUES? 

No 

Gender reassignment or transgender issues are not relevant to the 

subject matter of this Procedure or associated documents. The Local 

Backup Procedure and other information governance policies and 

procedures will be made available to all staff, regardless of gender. 









have a differential impact due to 

PREGNANCY OR MATERNITY? 



17. How have the Core Human Rights 

Values of: 

Fairness; 

Respect; 

Equality; 

Dignity; 

Autonomy 

The Local Backup Procedure and associated documents are made available in the 

document library and via the Weekly Bulletin for all staff. 

The Local Backup Procedure documentation will remain available to staff 

No on maternity leave or on return from maternity leave. Knowledge and 

skills following maternity leave will be updated using a hand over process 

between the member of staff returning to work and the member of staff 

returning to duty. 

There is nothing in this Procedure which would relate specifically to pregnancy or 

maternity leave, The Local Backup Procedure and associated documents are made 

available in the document library for all staff. 

The requirements and principles of the Data Protection Act, which is linked to the 

Human Rights Act, have been taken into account when writing this Procedure, 

including the individual rights of staff and patients as data subjects. Fairness in 

informing patients of the uses to be made of their data in a fair processing notice 

have been produced, respect for patient privacy, dignity and choice have been 

written into all Information Governance Policies produced and linked to this 

Procedure. 

Been considered in the formulation of this 

policy/Policy 

If they haven’t please reconsider the 

document and amend to incorporate these 

values. 






18. Which of the Human Rights Articles 

does this document impact? 

The right: 

Yes 

No 



• To life; 

• Not to be tortured or treated in an inhuman or degrading way; 

• To be free from slavery or forced labour; 

• To liberty and security; 

• To a fair trial – the need for a route and process of complaint 

is recognised and provided in the data protection leaflet made 

available to staff and patients; 

• To no punishment without law; 

• To respect for home and family life, home and 

correspondence – respect for patient wishes is taken into 

account in IG policies and privacy assessment tool is used 

when implementing new systems or uses of information; 

• To freedom of thought, conscience and religion; 

• To freedom of expression – patient choice has been a 

consideration in writing IG documentation, as well as the need 

for availability of differing formats and language as and when 

necessary; 

• To freedom of assembly and association; 

• To marry and found a family; 

• Not to be discriminated against in relation to the enjoyment of 

any of the rights contained in the European Convention; 

• To peaceful enjoyment of possessions and education; 

• To free elections 

No 

No 

All documentation produced as part of the Information Governance programme of 

work has taken account of the Human Right Act and this has been referenced where 

necessary. 

Yes 

Yes 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 






How will you ensure that those responsible 

for implementing the Policy are aware of the 

Human Rights implications and equipped to 

deal with them? 

19. Could the differential 

impact identified in 8 – 13 

amount to there being the 

potential for adverse impact N 

in this policy? 

20. Can this adverse impact 

be justified on the grounds of 

promoting equality of 

N 

opportunity for one group? 

Or any other reason? 

21. Should the policy 

proceed to a full equality 

impact assessment? N 

The Act has been referenced within the Procedure and any monitoring of compliance 

will include the awareness of patients and staff having a right to privacy, dignity, 

respect and choice. Training in Human Rights Act is also made available to staff. 

Any and all adverse impacts will be mitigated by adjustments indicated at times of 

additional needs. 

Please explain for each equality heading (questions 8 –13) on a separate piece of 

paper. 

If Yes, describe why, then proceed to a full EIA. 

If No, are there any minor further amendments that should take place? No 

If a need for minor amendments is identified, what date were these completed and 

what actions were undertaken. 

Signed (completing officer) ……… …………………………………….. Date 

Signed (Head of Section) ……………………………………………………….. Date 

Please ensure that a signed copy of this form is sent to both the Policies Officer and the Equality and Diversity lead to be placed 

on the Primary Care Trust website.

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