Δ Date of referral MM slash DD slash YYYY Name of Employer (Person in receipt of DP/PHB)* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City County Post code (If not already a current Cheshire ASASS / DP Client)Email PhonePreferred contact method and contact person if not the employer:Please confirm how you receive funding to direct your own care (please tick one) Direct Payment Combination of Social Care and Health funding Self-FunderPlease confirm you provides you with support (please tick one) Age UK Cheshire Disability Positive OtherIf other, please provide brief detailsReferrer details if not a self-referral (Name and organisation)Name First Last OrganisationAddress Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Please list any other training required:Training requiredEmployer TrainingPA's (Number of)Family (Number of)Preferred Training Provider / OnlineDate required Names of PA’s/Family requiring trainingNameEmail Address This field is hidden when viewing the formConfirmation* I hereby give consent to you passing this information to the Disability Positive Learning Service so they can commence arrangements for the training requested. I also consent to them passing my preferred contact details onto the training provider so they can contact me to arrange the training detailed above.Declaration* I have read and understood how you will use and process my data for this service, and I have informed my PA’s/family members of the information I may provide to you about them, in line with the privacy notice I also consent to them passing my preferred contact details onto the training provider so they can contact me to arrange the training detailed above.Signature*Date* DD slash MM slash YYYY Privacy Notice Learning Service Who We Are Disability Positive(‘we’ or ‘us’ or ‘our’)gather and process your personal information in accordance with this privacy notice and in compliance with the relevant data protection Regulation and laws. This notice provides you with the necessary information regarding your rights and our obligations, and explains how, why and when we process your personal data. Disability Positive’s registered office is at Sension House, Denton Drive, Northwich, Cheshire, CW97LU and we are a company registered in England and Wales under company number 4050994. We are registered on the Information Commissioner's Office Register registration number, and act as the data controller/data processor.Our designated Data Protection Officer for the organisation is Jon Findlay,who can be contacted at DPO@@disabilitypositive.orgor in writing to Data Protection Officer, Sension House, Denton Drive, Northwich, Cheshire, CW97LU Information That We Collect Disability Positiveprocesses your personal information to meet our legal, statutory and contractual obligations and to provide you with our services. We will never collect any unnecessary personal data from you and do not process your information in any way, other than as specified in this notice. The personal data that we may collect from is: -NameDate of BirthHome AddressPersonal EmailHome Telephone NumberMobile Telephone NumberSpecial Category DataHealth/Medical informationReligionYour opinions and wishes We collect information in the below ways: -Electronic referral forms Paper referral forms How We Use Your Personal Data (Legal Basis for Processing) Disability Positivetakes your privacy very seriously and will never disclose or share your data without your consent; unless required to do so by law. We only retain your data for as long as is necessary and for the purpose(s) specified in this notice. Where you have consented to us providing you with information on other services we deliver, you are free to withdraw this consent at any time. The purposes and reasons for processing your personal data are detailed below: - Learning ServiceWe collect your personal data in the performance of a contract between our service and Skills for Care.To provide you a safe and high-quality service.For monitoring and to identify additional gaps in services. How long will you keep this data for and why? Data will be stored on our Case Management System for 7 years for reporting purposes and to ensure we have accurate and relevant personal histories to offer appropriate services. If your case closes the information will be archived and stored until the 7-year limit is reached. How will my information be stored? Data will be stored on the secure Disability Positive IT system (Case Worker Connect online) and physical forms will be stored in secure filing cabinets. Monitoring data will be stored in encrypted format on Disability Positive’s secure servers. Your Rights You have the right to access any personal information that Disability Positive processes about you and to request information about: -What personal data we hold about youThe purposes of the processingThe categories of personal data concernedThe recipients to whom the personal data has/will be disclosedHow long we intend to store your personal data forIf we did not collect the data directly from you, information about the source If you believe that we hold any incomplete or inaccurate data about you, you have the right to ask us to correct and/or complete the information and we will strive to correct it as quickly as possible; unless there is a valid reason for not doing so, at which point you will be notified. You also have the right to request erasure of your personal data or to restrict processing (where applicable)in accordance with the data protection laws; as well as to object to any direct marketing from us; and to exercise your data portability rights. If we receive a request from you to exercise any of the above rights, we may ask you to verify your identity before acting on the request; this is to ensure that your data is protected and kept secure. Sharing and Disclosing Your Personal Information We do not share or disclose any of your personal information without your consent, other than for the purposes specified in this notice or where there is a legal requirement. Disability Positive uses third-partiesto provide the below services and business functions; however, all processors acting on our behalf only process your data in accordance with instructions from us and comply fully with this privacy notice, the data protection laws and any other appropriate confidentiality and security measures. Blue Door Software We use Blue Door Software to support our client database. They have access to all data in the capacity of a processor on our behalf. For more information about Blue Door Software, please read their Privacy Notice at https://bluedoorsoftware.co.uk/privacy-notice/ Data Space All physical forms and files archived are stored with Data Space and conform to ISO/IEC 27001:2013. For more information please read their Privacy Notice at https://www.data-space.co.uk/privacy-policy/ Efixer Our outsourced IT support has access to all electronic information to enable the company to deliver effective services. For more information please read their Privacy Notice at http://efixer.com/privacy.pdf Safeguarding Measures Disability Positivetakes your privacy seriously and takes every reasonable measure and precaution to protect and secure your personal data. We work hard to protect you and your information from unauthorised access, alteration, disclosure or destruction and have several layers of security measures in place,including: -SSL, TLS, encryptions, restricted accessIT authenticationfirewallsanti-virus/malware etc Transfers Outside the EU Personal data in the European Union is protected by the General Data Protection Regulation (GDPR) but some other countries may not necessarily have the same high standard of protection for your personal data. Disability Positive does not transfer or store any personal data outside the EU. Special Categories Data Owing to the services that we offer; Disability Positivesometimes needs to process sensitive personal information (known as special category data) about you to:Provide the correct level of support to you at groupsFor the safety and security of other group members, staff and volunteers.Where we collect such information, we will only request and process the minimum necessary for the specified purpose and identify a compliant legal basis for doing so. Lodging A Complaint Disability Positiveonly processes your personal information in compliance with this privacy notice and in accordance with the relevant data protection laws. If, however you wish to raise a complaint regarding the processing of your personal data in the first instance please contact: Disability Positive Lynne Turnbull Sension House, Denton Drive Northwich Cheshire CW97LU 01606 331 853 DPO@@disabilitypositive.org If you are unsatisfied with how we have handled your information, you have the right to lodge a complaint with the supervisory authority: Information Commissioner’s Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF Telephone: 0303 123 1113 (local rate) or 01625 545 745 (national rate) Email: enquiries@ico.org.ukI confirm that I have been provided with a copy of Privacy Notice & Terms & Conditions prior to giving consent* Please tick
