Primary School Nursing Program Student Referral Form (Page 2 of 4) in pdf

Section B

Information privacy statement for Parent/Guardian

Information about Privacy

1. What information will I be asked about in the referral form?

The information you are asked about includes:

• your child’s health history

• any concerns you may have about your child’s health, wellbeing and development

2. What is this information used for?

This information is used to:

• identify your child’s health needs

• determine the need for further health assessment of your child with your consent. Where clinically indicated,

this may include screening of your child’s vision, hearing, speech and language, a mouth check and general

development assessments

• give you advice based on these needs

• with your permission, share information with relevant staff of the school and the Department of Education and Training

to provide your child with appropriate support e.g. your child’s teacher, principal or student support officer

• manage, plan, improve and evaluate the delivery of school health services.

3. Why should I give this information?

This information is important in providing support for your child. It helps:

• the school nurse to understand any concerns you may have about your child’s health in order to undertake a health

assessment of your child

• the school nurse to offer advice and information about your child’s health and referral to other services if needed

• the school to understand how your child’s health may impact his or her learning.

4. Do I have to provide this information?

No, you are not required to provide this information, however, the information you provide will assist the school nurse to

support you and your child. If you choose not to provide this information, it is helpful to us if you can explain why.

5. How will this information stay private?

The Department of Education and Training and your school are committed to protecting the personal information you

provide us. Your information will only be used and disclosed in ways outlined above and will not be used for any other

purpose without your consent, unless required by law.

6. Accessing your information.

You may access the information held by the school nurse or the Department of Education and Training.

For more information please contact the School Nursing Manager at your local Department of Education and Training

office listed on the back page of this form.

Thank you for completing this form.

Primary School Nursing Program Student Referral Form Page 2