You are being referred to Healthywork Ltd, an Occupational Health service. In order for us to formulate appropriate advice, we need your consent to go ahead with the appointment using relevant information from the Referrer (1. below). There is also the option to read the report following the input, before release, where it includes health/sensitive information (2. below).
1. Personal details
Full Name:
Home Address:
PERSONAL email address:
Mobile number:
(The Healthywork Ltd ‘UK GDPR - Information notice to Individual Clients’ is also available at the end of this Consent Form).
By completing the section above, I Agree to input from Healthywork Ltd. Also, for the Referrer to share any relevant work related information and health related information (as held by the Referrer) with Healthywork Ltd.
2. READ THE REPORT BEFORE RELEASE to Referrer – if medical/sensitive information is in the report
Following the assessment a detailed written report will be compiled, including recommendations and workplace ‘reasonable adjustments’ (under the Equality Act 2010) for your employer to consider. Also if there are any workplace issues, e.g. with tasks, work relationships etc. the Assessor will aim to detail these sensitively, in order that they can be addressed.
The report also includes information/links which may be beneficial to your Referrer/employer but also for you, e.g. further condition management treatment advice and self-help information, including Crisis Support information, (some will be emailed to you immediately following the assessment).
You can conduct the ‘Read report before release’ process to review the ‘Draft’ report content and indicate any corrections/comments/additions to the report, in writing (by email) to the Assessor. The report will be password protected (texted or emailed separately) as it includes confidential personal/medical information.
The Assessor will then consider any comments you made and consider amendments to the report (There may be back and forth updated versions of the report during this report review period).
By the end of this process, you will have an electronic copy of the ‘Final’ report version which will be submitted to the Referrer/report recipient(s) on an indicated date (or extended in discussed and agreed circumstances between you and the Assessor).
Where there is no engagement/communication from you, despite our efforts to do so, the report titled ‘Draft’ report will be converted to ‘Final’ report for the report to be submitted on the date agreed (or on the extension submission date agreed with you) then sent/emailed along with a text message to you, with a short period of time to respond (minimum 2 hours) prior to actual submission by email to the Referrer, in order that there is an opportunity for information in the ‘Final’ report to be redacted as an option subject to your decision.
If you have visual/health needs impacted by screen use, do not have an electronic device or have a device on which it is difficult to read a long report, e.g. small mobile phone screen access only, or do not use email, the Draft report can be sent by an alternative method. Discuss this with the Assessor at the assessment.
I wish to ‘read the report before release’ to the Referrer so have provided my PERSONAL email address and my mobile number in Section 1 above.
Date this form is completed:
Please sign at the end of the document, thank you.
UK GDPR - Information Notice to Individual Clients from 25.05.2018
Privacy Information
Healthywork Ltd is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when working with Healthywork Ltd, you can be assured that it will only be used in accordance with this privacy statement.
|
Name and contact details of the Data Controller
|
Alison Biggs - Director
T: 07958 502363
E: alison@healthywork.org.uk
|
|
Data Processors
|
Any Associate professional conducting input for Healthywork Ltd
|
Why we collect and process your data
We always ask for your consent to process your data in order to provide our specialist services to you.
How and what information is collected about you
We may collect the following information by email, telephone call, by post, questionnaires / forms, or in-person:
- Name and Date of Birth
- Contact details (phone, email, address)
- Family members / Support Staff names and contact details
- Personal health and lifestyle information, including reports and letters from healthcare professionals.
- Referral information and assessment/input outcomes
What we do with the information we gather and what it is used for
- Professional record keeping of client information.
- Recording the initial assessment/provision of services.
- Sharing your information with relevant parties when necessary (with your permission)
Your Rights
- If you have given your consent to us processing your data, you have a right to withdraw your consent to any further processing.
- You have a right to request your data to be erased from our records.
- You have the right to request your data be transferred to another organisation.
- You have the right to access personal data and supplementary information.
- You have the right to have inaccurate personal data rectified, or completed if it is incomplete.
- You have the right to restrict/object processing in certain circumstances.
If you wish to withdraw consent or request a transfer or erasure of your data, please email alison@healthywork.org.uk.
We will always give you the opportunity to opt out of future marketing whenever we send you marketing material, or you can opt out at any time by contacting us.
How you can access your information
You may request details of personal information which we hold about you under the UK GDPR. If you would like a copy of the information held on you, please write to Alison Biggs at Healthywork Ltd, PO Box 545, Abbots Langley, Hertfordshire, WD5 5AN. There is no longer a charge for this service.
How long we keep your information for
The Regulation does not set out any specific minimum or maximum periods for retaining personal data. Instead, it says that: Personal data processed for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes. See this link: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/principles/storage-limitation/
Healthywork Ltd will retain personal data for 7 years for adults and 7 years following their 18th birthday for children, unless upon review it is deemed necessary to retain it for a longer period.
Data Transfer outside the European Union
In some instances, it may be necessary for us to transfer your data outside of the European Union, or to countries not approved by the ICO. Where this is the case, we will seek further consent from you to do this. In all instances, we will take all steps necessary to safeguard your information and ensure that your data protection rights are maintained.
Security
We are committed to ensuring that your information is secure. In order to prevent unauthorised access or disclosure, we have put in place highly secure electronic systems and managerial procedures to safeguard and secure the information we collect.
Right to Complain
If you have a concern about our information practices, you have the right to complain. You can do so by contacting the Information Commissioner’s Office on 0303 123 1113 or by visiting www.ico.org.uk
