DWP Provider Guidance ESF 2014 – 2020
Annex 4 - Informed Consent Statement

We work in [detail area your contract covers] with other organisations/partners to make sure that you receive all the services you need, when you need them. We want to focus on your particular needs to make sure that you get the right support.

Sharing your information will help us to support you better by:
•	Helping the team give you the best advice about services in your local area
•	Helping partners understand how they can improve services to you
•	Allowing the team to contact you to provide help and support with any problems you may have or which may worry you (for example housing issues)
•	Offering help and support to you by talking about your needs and how partners can help.
To help us do this, we want to share your personal information with each other. The exchange of information will take place, mainly during case conferences attended by representatives of some or all of the partners listed below.

The information we may share is about:
•	Your name; date of birth; address, contact telephone number and contact email address
•	Benefits received and support to find employment (for example which benefits you received, when these are due for review, support you are being provided to become more ready for work, conditions of your benefit receipt and when these may change)
•	Transport issues (access to transport)
•	Housing matters (for example tenancy type, rent arrears, fixed abode)
•	Family matters (for example your current and former relationships, children and stepchildren, domestic routines and environment)
•	Health information (for example any disabilities , illnesses, mental health problems, addictions/dependencies, support you receive)
•	Relevant police and probation information (for example any conditions that you are under, previous convictions, police involvement at your address)
•	Qualifications, work history and career aims
The other agencies we will work with are:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

We will only share your personal information for reasons mentioned above unless the law says we are required to share it for another reason, or as believe we must share the information to protect you or others. If in this process we obtain information that is relevant to benefits that you receive we may contact you further to ensure your entitlement is correct.

Your personal information will be stored securely and retained until the end of the provision or until you withdraw consent.

You may withdraw your consent by contacting [insert contact details]

Consent to share your personal information

I …………………………………………………………………………… (print full name)
Have had the above information explained to me, including any consequences of not sharing Health/Social Care information. 

Signed ………………………………………………………….. Date ……………………

Provider signed ………………………………………………... Date …………………… 

I am/am not happy for you to share any relevant Health/Social Care information and understand that I can change my mind at anytime

Signed ………………………………………………………….. Date ……………………

I am happy for you to share any relevant Health/Social Care information apart from (please tell us below) and understand that I can change my mind at anytime

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Signed ………………………………………………………….. Date ……………………