Appendix 3: Form the Area Health Service can require medical students to sign

NOTE: YOU ARE NOT REQUIRED TO SIGN THIS FORM BUT YOU MUST SIGN AND RETURN THE OTHER FORM STUDENT UNDERTAKING

Undertaking to observe privacy requirements

I, (name) understand that, while I am (employed/contracted*) by the (name of health service) , I may have access to personal health information collected for purposes of client/patient care or for administrative, statistical or other purposes. Such personal information includes the identity of, and personal and health information about individual persons.

I undertake not to knowingly access any personal health information unless such information is essential for me to properly and efficiently perform my (duties/contractual obligations*).

I recognise and accept that my access to, holding and use of this information is subject to the Health Privacy Principles contained in the Health Records and Information Privacy Act 2002 (see Appendix 6) and undertake to comply with those principles and relevant NSW Health policies affecting the collection, holding use or disclosure of the information.

In order to fulfil this undertaking, I will not divulge any personal health information regarding individual persons, except as allowed by the Health Privacy Principles.

I also undertake to follow other information privacy and security procedures as stipulated by NSW Health policies in relation to any personal health information which I access in the course of my (duties/contractual obligations*).

In order to fulfil this undertaking I will ensure that, so far as it is within my control, such information, whether in the form of paper documents, computerised data or in any other form, cannot be viewed by unauthorised persons, and that the information is stored in a secure and orderly manner which prevents unauthorised access.

I further undertake to inform (my supervisor/title of relevant officer*) immediately if I become aware of any breach of privacy or security relating to the information which I access in the course of my (duties/contractual obligations*).

* delete as required

Signed ...........................................


Witnessed ...........................................