How To Consent To A Disability Care Program

Transcription

1 VOCATIONAL REHABILITATION (VR) PROGRAM CONSENT FOR THE VR PROGRAM TO OBTAIN INFORMATION ABOUT ME AND PRIVACY NOTICE The VR Program is a program of the Manitoba Department of Family Services and Consumer Affairs. The VR Program works with other agencies, organizations and employers to provide a broad range of assessment, vocational and employment services to eligible participants who are living with a disability. Why the VR Program needs to collect information about me 1. I understand that the VR Program needs to collect: personal information about me, such as information about my education and employment history, and vocational information; and personal health information about me, such as information about my disability and other medical and psychological information; for the following purposes: to determine and verify if I am eligible for services provided by the VR Program; to assess my needs, develop a vocational plan and provide me with VR Program services; to monitor and record my participation and progress in the VR Program; to administer and enforce the VR Program; and for VR Program research, planning, reporting, evaluation and accountability purposes. Page 1 of 5

2 2. I understand that the VR Program will limit collection, use and disclosure of my personal information and personal health information to the minimum amount necessary to carry out these purposes. Information I agree to provide to the VR Program 3. I agree to provide personal information, personal health information and other information that the VR Program determines is necessary to carry out the purposes described above in paragraph 1. I understand that the information I will be asked to provide will include: my full name, address and telephone number; my birth date; my gender; my Social Insurance Number; my Employment and Income Assistance (EIA) number, if I receive EIA; my education, job skills, experience and credentials; nature and onset of my disability; my sources of income; any legal restrictions that may impact on my vocational or employment objectives; my employment status before and upon being enrolled in the VR Program, while I am participating in the VR Program and, on request, for up to five years after I stop participating in the VR Program; programs, assistance and services provided to me by the Manitoba Department of Family Services and Consumer Affairs (such as Employment and Income Assistance) before being enrolled in the VR Program and while I am participating in the VR Program. Consent to the VR Program obtaining information about me from other sources 4. I consent to the following persons and entities disclosing to the VR Program personal information and personal health information about me that is necessary to carry out the purposes described above in paragraph 1: my school(s) and educational institution(s): ; my current and past employers: Page 2 of 5

3 my physician(s): my ophthalmologist [insert name] ; my audiologist [insert name] ; my psychologist(s) or psychiatrist(s) my other health care provider(s) [insert names] ; the Community Mental Health program of the Regional Health Authority; the Manitoba Employment and Income Assistance Program; any other Manitoba government department or agency, or federal government department or agency, that has provided or is providing me with rehabilitation, training or employment related services, assistance or support, including: any other agency or entity that has provided or is providing me with rehabilitation, training or employment related services, assistance or support, including: [insert names]. 5. I also consent to the VR Program collecting personal information and personal health information about me from these persons and entities, and to the Program providing such personal information to them as may be necessary to obtain the information the Program requires. How long does my consent last? 6. I agree that the consents I have given will last for five years after the VR Program advises me that my file is closed or for five years after I have voluntarily withdrawn from the VR Program. This five year period is necessary to properly monitor and evaluate the VR Program. Page 3 of 5

4 Can I withdraw my consent? 7. I understand that I may change or withdraw my consent at any time, in writing. 8. However, I also understand that, if I change or withdraw my consent, I may no longer be eligible to receive the full range of services available through the VR Program or to participate in the VR Program. Name of Applicant (printed) Date Signature of Applicant or Authorized Representative, if applicant unable to sign, and relationship Optional consent to future contact for client surveys In order to determine if the VR Program is successful in meeting its goals, the VR Program or Human Resources and Social Development Canada may need to carry out client surveys. Your experience and views will be helpful to us. Please indicate below your interest in future surveys which are limited to: the VR Program or Human Resources and Social Development Canada and their agents, contacting you in the future for client surveys; and the VR Program providing your name, address and phone number to our agents, and to Human Resources and Social Development Canada and their agents, for the purpose of client surveys. This consent is limited to 5 years after your file with the VR Program is closed. You may withdraw this consent at any time, in writing. Also, your consent to being contacted about client surveys is voluntary and does not affect your eligibility for VR Program services. Yes, I consent, No, I do not wish to be included Date: Signature of Applicant or Authorized Representative, if applicant unable to sign, and relationship Page 4 of 5

5 PRIVACY NOTICE Why your information is being collected ("purposes") The VR Program needs to collect and use your personal information and personal health information for the purposes described in paragraph 1 on page 1. The legal authority to collect your information Your personal information and personal health information is necessary to carry out the activities of the VR Program and to provide you with VR Program services. Your personal information is collected under the authority of section 36(1)(b) of The Freedom of Information and Protection of Privacy Act and your personal health information is collected under the authority of section 13(1) of The Personal Health Information Act. We limit the personal information and personal health information we collect about you to the minimum amount necessary for the purposes described in paragraph 1 on page 1. Your personal information is protected by The Freedom of Information and Protection of Privacy Act of Manitoba and your personal health information is protected by The Personal Health Information Act of Manitoba. We cannot use or disclose your information for other purposes unless you consent or we are authorized to do so by The Freedom of Information and Protection of Privacy Act or The Personal Health Information Act. Who to contact with questions about collection of your information If you have any questions about the collection of your personal information or personal health information, please contact:, phone number: (Copy provided to applicant; original place on applicant's file) Page 5 of 5