Optivia Permissions | Blossom Antenatal: Antenatal Classes

Permissions Form – Use of Personal Data

1. What is the General Data Protection Regulation?
The General Data Protection Regulation (GDPR) is a law that protects the privacy and security of individuals' data. It is important for us to ask your consent about how we plan to use your data.

2. How will we use your data?
Funded by Public Health, the Optivita pilot will use the information you supply to help you achieve your health and wellbeing goals, and with your consent refer you to other local partners who can also assist you. As part of our funding requirements, Blossom will share data that does not identify you as an individual with our funders. This data will also be used as part of a published evaluation being completed by Imperial College London to review the pilot. A short summary of the work we do with you will also be made available on the patient record systems JOY and the Electronic Medical Information System (EMIS) which is used by GPs to help provide the best care they can for you and your family. We will also ask you to complete a wellbeing questionnaire as part of our support.

3. What sort of data will we use?
This data is anonymous, and it will not identify you as an individual. To improve the support we offer, and to find out what has worked well, some families may be asked to complete survey questionnaires, agree to be interviewed by the Imperial College London evaluation team (with appropriate interpreter support if needed), share short videos or be part of a case study which may identify them. A separate consent form will be provided for these additional requests.Personal data will be kept on secure NHS servers and Blossom systems for a period of ten years, in accordance with the Blossom ‘Data Protection and Privacy Policy’which can be found at www.blossomantenatal.com/privacy-notice. After this period all data will be deleted. Please read before giving consent.

4. Consent
By consenting, you are confirming that you understand how your/your family’s data will be used. You can withdraw your consent at any time by sending an email to optivita@blossomantenatal.com, but please be aware it will not be possible to remove your data from any published material created prior to your instruction.

Please tick (✓) the options below you are happy with:

I/we give permission for you to collect and store information securely and share as necessary as detailed above as agreed by myself /my family.

I/we give permission for my/my families information to be used by Imperial College London for the Optivita evaluation.

I/we give permission for my information to be shared with my GP Practice.

I am happy to be contacted in the future to follow up on my experiences with your services. I understand that participation is entirely voluntary, and I can choose not to take part if contacted.

EMIS ID

Parents Name

Signature

Date

Children

Childs name