Participant Informed Consent Form

Name of participant *

Name of representative (if applicable)

Part A - Data Collection Information

Information about your needs allow for your provision of services so our team can:

decide if we can provide a service that suits your needs
develop a person-centred plan
create a roster/schedule
develop an individual medication plan (if applicable)
share information with support staff
share information with other providers or people to develop a comprehensive plan

This form allows you to tell us who we can and cannot share information. If you decide to withdraw your permission after signing this form, you can update your consent by contacting management.

I consent to disclose information to the following people and/or organisations; please the box for services that you agree we can receive and share information with, specific to your support service needs; *

YesNo

I give consent and permission for this Organisation to collect and hold my personal information *

YesNo

Please specify specific consent authorisations here:Add relevant people of agencies –Doctors, Allied Health, Plan Managers, SIL/SDA providers, education providers

Part B - Privacy Information

Privacy and confidentiality

Personal information collection, holding, use and disclosure of personal information by this Organisation is protected by the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act).

Personal information is any information or an opinion that identifies you or could identify you and includes information about your health.

Any personal information held by our Organisation is protected under the National Disability Insurance Scheme Act 2013 and the Privacy Act 1988. Our Organisation will only disclose relevant and/or necessary information to any external parties you have permitted us to disclose information unless required by law.

Personal information and documents

The purpose for collecting personal information from you is to:

provide services, including planning, coordinating, funding, implementing, monitoring and reviewing our services
report to NDIS, government or other funding bodies of how funding is used by us,
take photographs and videos for therapeutic and marketing purposes
responding to your feedback, and
responding to your queries.

This Organisation will not disclose/use information about you for any secondary purpose unless:

You have consented to the use or disclosure; or
You would reasonably expect us to use or disclose the information for the secondary purpose as it is directly related to the primary purpose; or
The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal order; or
Our Organisation reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to life, health or safety of an individual or public health and safety; or
Our Organisation has reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to organisational functions or activities;
Our Organisation reasonably believes that the use or disclosure is reasonably necessary to assist another person in locating a person reported as missing.

Photographs and videos for purposes of support provision only *

Yes No

Photographs and videos to be shared with family *

Yes No

Do you give permission for photographs and videos to be used for commercial or marketing purposes? *

Yes No

Allow to assist with medication (refer to Management of Medication documentation, if yes) *

Yes No

Assist with handling money *

Yes No

As registered Disability Service Providers, we are obligated to undergo regular audits to comply with our legal requirements. Part of this audit process involves auditors contacting some clients to discuss the services you receive and your level of satisfaction. We are seeking to confirm if you give your consent for the auditors to contact you and review your file and records Your participation is not compulsory. You can opt-out if you do not want to be involved.

I consent to participate in an audit if approached by the auditor *

YesNo

Part C - Authorisation

Full Name *

give authority for the Organisation; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs under the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) whilst I/we remain a participant of this Organisation. I am aware that recorded material in audio and/or visual format and outline can be shared without consent if required by law.

If my/our circumstances change, I agree to notify this Organisation as soon as practicable.

I understand the information shared may include personal information within the meaning of The Freedom of Information and Protection of Privacy Act and personal health information within the meaning of The Health Information Protection Act.

I further understand that the Organisation will only release as much information as is needed to respond to my concern and subject to the restrictions and provisions of The Freedom of Information and Protection of Privacy Act 2012 (Cth) and The Health Information Protection Act.

To comply with privacy legislation, consent is necessary when participants ask third parties to either advocate or make inquiries on their behalf regarding various issues or services the Organisation provides.
In all cases, the Organisation will only release as much information as is needed to respond to the inquiry or participant’s concern.
The Organisation will not release certain information, e.g. information about other individuals, records subject to solicitor-participant privilege, records relating to a current lawful investigation, records the release of which would affect the safety or health of anyone).
If a subsequent inquiry is made by the same third party unrelated to any previous participant concern, another consent form will need to be completed.

Note: Where a participant does not have the capacity to give informed consent and does not have a legal guardian who has the authority to make decisions on behalf of the participant, the participant’s parent, family member or other people with a close personal relationship to the participant may sign this form. The person who signs on the participant’s behalf must print their relationship next to their name.

Full Name *

Date signed *

Signature *

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