By signing this form, the Worker gives their consent for medical information about themselves as assessed by a Health Professional to be released to %The_Company%’s Health and Safety Representative. Where this information indicates that the Worker may not be able to perform their job functions safely or that their health may have been adversely affected, the information will be passed on to the Worker’s Manager.
I ……………………………………………………..authorise %The_Company% appointed Health Assessor to collect and release job related health information about myself to my PCBU.
I understand that the health information collected and released by the Health Assessor will relate only to baseline health measurements and medical assessments of my ability to perform my job safely.
I understand that in the collection, use and storage of this information, my PCBU will comply with the obligations of the Privacy Act 2020 and the Health Information Privacy Code 1994. I understand that, within the provisions of the Privacy Act and the Code, I have the right of access to and I may ask for correction of, information that my PCBU holds about myself.
The information privacy principles of the Privacy Act 2020 and HIPC ensure that with certain exceptions:
- The least possible amount of personal information must be collected to meet PCBU needs.
- The individual concerned must know of, and consent to, the collection of personal information.
- The information is kept securely.
- Worker has right of access to, and correction of, information about themselves which an PCBU obtains.
- The information is only used for the purpose for which it was collected.
- There are limitations on what information can be released by a PCBU.If you have any concerns about the way in which your personal information has been handled, you should discuss the matter with your manager. If you still have concerns, you have the right to lodge a complaint with the Privacy Commissioner, PO Box 466, Auckland 1, Free Phone 0800 803 909.Worker Signature:_____________ Date:___________