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D: Privacy, data sharing and declaration

Consent for disclosure and use of personal information

I understand that under a Data Sharing Agreement between the Barossa Hills Fleurieu Local Health Network Incorporated (BHFLHN) and the Commonwealth of Australia (Commonwealth) relating to the evaluation of National Rural Generalist Pathways, BHFLHN is required to collect personal information about participants, including myself.

I understand that for the purposes of this consent, “personal information” is any information or an opinion, whether true or not, relating to me or my affairs where my identity is apparent, or can reasonably be ascertained, from the information or opinion, and that this includes the following types of information:

my name;
date of birth;
gender;
country of birth;
citizenship;
my medical registration number and Medicare provider number;
education and training activity information relating to myself, including, but not limited to: details of the primary and secondary schools and the universities that I have attended, any additional skills and training that I have received, any GP training programs that I have participated in and details of my participation in the National Rural Generalist Pathway; and
details of any funding or scholarships that I may have received.

(“Personal Information”)

I consent to the collection, storage, disclosure and use of my Personal Information for the the purposes of evaluating the Rural Generalist Program South Australia and the National Rural Generalist Pathway, and I specifically consent to BHFLHN disclosing my Personal Information to the Commonwealth for this purpose. I understand that for the purposes of evaluating the Rural Generalist Program South Australia and the National Rural Generalist Pathway my Personal Information may be used by the South Australian Government or the Commonwealth for (including but not limited to):

evaluating the degree to which the state or national workforce distribution objectives are being met since the implementation of the Rural Generalist Program South Australian and the National Rural Generalist Pathway;
assessing if jurisdictional Rural Generalist programs have contributed towards enrolments into GP training programs; and
informing the development, implementation and management of workforce planning programs and policies.

I understand that BHFLHN will only collect, store, disclose and use my Personal Information in accordance with the Government of South Australia’s Information Privacy Principles Instruction.

I understand that both BHFLHN and the Commonwealth will treat my identifiable Personal Information as confidential information and will de-identify and aggregate my Personal Information prior to using it as part of any publicly available report.

I understand that the Commonwealth will only collect, store, disclose and use my Personal Information in accordance with the Privacy Act 1988 (Cth).

Signed Declaration

I of , , , , hereby consent to the collection, storage, disclosure and use of my Personal Information in the manner outlined above in this form.

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Timestamp

Audit

April 26, 2022 10:19 am ACST

D: Privacy, data sharing and declaration Uploaded by Johanna Milbank - health.SARuralGeneralistTraining@sa.gov.au IP 143.216.105.219

April 26, 2022 10:30 am ACST

Rural Generalist Coordination Unit - health.SARuralGeneralistTraining@sa.gov.au added by Johanna Milbank - health.SARuralGeneralistTraining@sa.gov.au as a CC'd Recipient Ip: 143.216.105.219