Test Page QPP Consent Form Form Completed On DD slash MM slash YYYY CLIENT DETAILSName(Required) First Last Do you have a preferred name?(Different than your first name above) No Yes Preferred name(Required) Date of Birth(Required) Day Month Year Home Address Street Address City State/Territory Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman 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 QPP USE ONLYWhere this form is being completed and signed by a parent or guardian, please indicate responses on behalf of the client.What consent is required?(Required) QPP Client QPP & HPHT CCCM Client HPHT CCCM Appendix Only Aged Care Navigation Client Consent is given by:(Required) Client (on own behalf) Parent or Guardian for person under 18 years old (on behalf of client) An Authorised Substitute Decision Maker* for the client *Under the Powers of Attorney Act 1998 and the Guardianship and Administration Act 2000, if the client is an adult and unable to give consent, an authorised decision maker must give the consent on the client’s behalf.The legal capacity of the Authorised Substitute Decision Maker is (e.g. EPOA):Evidence of the Authorised Substitute Decision Maker’s authority has been sighted/obtained.(Required) Yes No CULTURAL / INTERPRETER NEEDSIs an Interpreter required?(Required) Yes No Is a registered interpreter present?(Required) Yes No Do you have a support person?(Required) Yes No Is your support person present?(Required) Yes No THE BELOW IS TO BE COMPLETED IN THE COMPANY OF A QUEENSLAND POSITIVE PEOPLE STAFF MEMBERWhere this form is being completed and signed by a parent or guardian, please indicate responses on behalf of the client.CLIENT CONSENTI agree and consent to: (please indicate Yes or No for all points of consent)The service has been explained to me and I consent to Queensland Positive People (QPP) providing services to me.(Required) Yes No I have been given a Client Information Handbook.(Required) Yes No I understand the ‘Consent and You: Understanding QPP’s Consent Policy’ sections which outlines:(Required) What information QPP collects Who will have access to my client file Sharing my information for reporting purposes The limits of confidentiality Select AllI give general consent to QPP sharing my information with other people or services to assist in providing support to me.(Required) Yes No At support closure, I consent to QPP advising relevant services who have been working in partnership with me that QPP has closed my case.(Required) Yes No I understand that even if I give consent now, I can amend or withdraw consent at any time in the future. This consent form will be reviewed with me at least annually.(Required) Yes No AGED CARE NAVIGATION CLIENTS ONLYSome basic information will be shared with Care Finder consortia partners (Micah and Communify) to assist with intake and allocation. I have been advised that consortia partners must also adhere to Queensland Privacy Laws(Required) Yes No HPHT CCCM CLIENTS ONLYThis section covers the specific information sharing arrangements required between the HIV Public Health Team (HPHT) and QPP. I understand and consent that QPP are required to provide regular information and updates to HPHT regarding the support they have requested QPP provide for me.(Required) Yes No I understand and consent to QPP working collaboratively and sharing information relevant to my support with HPHT.(Required) Yes No I understand and consent that if I lose contact with QPP, basic information (such as appointment attendance or medication collection) is still required to be shared with HPHT.(Required) Yes No EXCLUSIONS AND CONTACT PLANSQueensland Positive People provides clients with options for information sharing with other services / peopleConsent Exclusions(Required) I DO NOT give consent for QPP to share information with the following services/people: Not applicable Service / Person's Name Comment Service / Person's Name Comment Service / Person's Name Comment Alternate and Emergency Contact Plane.g. If unable to reach me after 5 days of contact we had planned OR in an Emergency I give consent for QPP to contact in the following circumstances: Circumstances Name Contact Details Identify from QPP? Yes No Circumstances Name Contact Details Identify from QPP? Yes No CLIENT AUTHORISATION(or signature and name of the authorised guardian or substitute decision maker).Consent being given:(Required) In Writing Verbally Client Signature(Required)Client Name(Required) QPP Staff Member(Required) The name of the QPP staff member who explained this form and consent is to youDate (todays date) DD slash MM slash YYYY WITNESS STATEMENT OF WRITTEN CONSENT(The QPP staff member explaining this form to the client)Witness Signature(Required)Witness Name(Required) I confirm that I have verbally explained this information and witnessed the signing of this consent formPosition(Required) Date Witnessed DD slash MM slash YYYY VERBAL CONSENT IF APPLICABLE (QPP USE ONLY)Verbal Consent All components of the consent form have been discussed with the client / representative and they have consented to the sections above as indicated QPP Staff Member Signature(Required)Name(Required) Position(Required) Date DD slash MM slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.