NHS - Policy

Appendix F

CONFIDENTIAL DOCUMENT

Data Protection Disclosure Record

This form is to be used to record applications for the disclosure of Staff, Contractors or Patients Personal Data to external sources.

This document must be read in conjunction with the following Laws and Codes of Practice:

APPENDIX F: DATA PROTECTION, CONFIDENTIALITY & DISCLOSURE POLICY VERSION 2.1

AUTHOR: INFORMATION GOVERNANCE OFFICER DATE: FEBRUARY 2015

Page 1 of 4 DATE OF NEXT REVIEW: MARCH 2018

NHS - Policy

Data Protection Act 1998

Access to Health Records Act 1990

NHS Code of Practice: Confidentiality

Computer Misuse Act 1990

Police & Justice Act 2006

Access to Health Records Act 1990

APPENDIX F: DATA PROTECTION, CONFIDENTIALITY & DISCLOSURE POLICY VERSION 2.1

AUTHOR: INFORMATION GOVERNANCE OFFICER DATE: FEBRUARY 2015

Page 1 of 4 DATE OF NEXT REVIEW: MARCH 2018

NHS - Policy

The disclosure of information will only be granted if the appropriate Laws and Codes of Practice authorise disclosure.

Please complete the following details:

Police Reference Number:

Details of Person Making the Enquiry:

Name: / Date: / Time:
ID Number:
Job Title: / Email:
Address
Telephone Number:
Extension Number:
Post Code: / Mobile:

Initial Method of Contact:

Phone: / Email:
Fax: / Letter:

Verification and Authentication of the above Persons Identity:

Warrant Card: / Call to Main Switchboard:
Other: / Please specify:

DP 2 Received: Under Section 29(3) of the Data Protection Act 1998 the Police must provide a DP2 Form requesting the release of information and the reason for release.

Yes: / No:

All disclosure requests must be approved by the Caldicott Guardian, IG Manager or a Senior Manager within the Trust.

PLEASE ADD THE NAME, HOSPITAL NUMBER, ADDRESS ETC OF THE SUBJECT (PERSON ABOUT WHO THE INFORMATION IS REQUESTED) IN THE ADDITIONAL SUPPORTING INFORMATION SECTION.
Is the request for Disclosure compliant with?

Section 29(3) of the Data Protection Act 1998 / Yes / No
NHS Code of Practice: Confidentiality / Yes / No
Computer Misuse Act 1998 / Yes / No
Police & Justice Act 2005 / Yes / No
Child Protection Law / Yes / No

Did you discuss the disclosure of this information with another person?

Yes: / Please complete the person’s contact details in the boxes provided
No: / If no please state why in the box below
Contact Details:
Name: / Date: / Time:
Job Title:
Department / Email:
Telephone Number:
Extension Number:
Mobile:
Contact Details:
Name: / Date: / Time:
Job Title:
Email:
Address
Telephone Number:
Extension Number:
Post Code: / Mobile:

Has the Consent of the subject been sought before disclosure?

Yes: / No: / If no please state why in the box below

If a disclosure is to be made please indicate the reason for disclosure.

Personal Safety: / Prevention & Detection of a Crime:
Child Safety: / Other: / :
Other: / Please specify:

Will the disclosure result in an intervention on Trust premises?

Yes: / Contact the Trust Security Manager / No:
and record the location in the box below.
Give details of the exact location and time:

What Systems and Records have been searched?

Current Systems:
System: / Date: / Searched By:
iPM:
Euro King
Symphony
Telepath
Results Reporting
Lotus Notes
PACS
CRIS
ESR
Medical Photography
MLE
Finance
Clinician’s View
Sexual Health
Archived Systems:
System: / Date:
System:
Telepath
Histopathology
Cytology
Lotus Notes
Personnel Records
Photo

Details of Person Authorising Disclosure i.e. Caldicott Guardian, IG Manager, Duty Manager

Contact Details:
Name: / Date: / Time:
Job Title:
Signature: / Email:
Telephone Number:
Extension Number:
Mobile:

What Information was disclosed?

Type Records: / Number of Documents:
Date and Time of attendance
Names & Addresses
PACS Images
CCTV Footage
Staff Records
Corporate Record
Letter from Consultant
Date and Time of attendance
Test Results
Photographs
Number of Documents Released:

How was the Information Disclosed?

Phone: / Email:
Fax: / Letter:
Date: / Time:
Released by: / Job Title:
Encryption:

Additional Supporting information:

A completed copy of this document must be submitted to the IG Manager via the email box or sent in the internal post marked Confidential for addressee only to ensure all disclosure requests are logged within the Trust.

APPENDIX F: DATA PROTECTION, CONFIDENTIALITY & DISCLOSURE POLICY VERSION 2.1

AUTHOR: INFORMATION GOVERNANCE OFFICER DATE: FEBRUARY 2015

Page 1 of 4 DATE OF NEXT REVIEW: MARCH 2018