CONSENT FOR SHARING DATA WITH DIABETES NSW OPERATING THE LIFE FOR A CHILD

PATIENT DETAILS

First Name: ………………………………………………………….… Surname: ………………………………………..……………

Date of Birth: □□ □□ □□□□ ID Number: ……………………………….………………...

DD MM YYYY

UMR Number: ……………………………………………………

Please tick the box that applies.

□ I am the patient □ I am the parent/guardian of the patient □ I have power of attorney

During the period of the memorandum of understanding between Kenyatta National Hospital (KNH) and
Life For A Child (LFAC), LFAC will support the care of youth with diabetes mellitus at KNH with free
glucose meters, glucose strips and lancets.

For purposes of accountability and to guide future support, KNH will share group/pooled data with LFAC
from your medical records that may include information such as number of youth supported, their age,
the types of insulin they are using, average HbA1C and information on diabetes-related complications.

KNH will not share your individual data or any information that directly identifies you such as your
name, address or other contacts, date of birth or hospital identification number.

The information shared with LFAC will be used solely for programme monitoring and clinical audits, and
no research will be conducted without your consent.

You have the right to withdraw your permission for KNH to share your information with LFAC. If you
withdraw your permission, this will not affect the routine diabetes care you receive at KNH.

Please tick the box that applies.

□ I agree to my de-identified information being shared with LFAC.

□ I do not agree to my information being shared with LFAC.

Signature: ……………………………………..…. Date: ………………………………………….

Should you have any questions about this process, or wish to withdraw your consent please contact
+254722431743