ndss.com.au NDSS Registration Form

1 NDSS Helpline 1800 637 700. NDSS Registration Form About this form For what purpose do we use or disclose your information? This form allows you to register with the National diabetes We use or disclose your personal and sensitive information Service Scheme (NDSS) and the National Gestational for the purposes of administering the NDSS and providing diabetes Register. programs, services, and activities. The NDSS is an initiative of the Australian Government We may use your information to: administered by diabetes Australia. The NDSS provides confirm your identity and update your personal details people with diabetes who are registered access to information and resources, diabetes self-management education provide you with information about the NDSS, managing your diabetes or sending reminder notices to you and programs, and a range of subsidised diabetes products.

2 Your health professionals about important aspects of your The National Gestational diabetes Register provides postnatal diabetes management reminders to women with gestational diabetes and their invite you to participate in education, support services and nominated GP. The register aims to help these women reduce programs delivered by diabetes Australia or your local their risk of developing type 2 diabetes and manage their state and territory diabetes organisation, or other NDSS. health into the future. programs requiring specific consent provide training to you, (or if you are a student to your Your privacy school's staff), on diabetes and diabetes management The information you provide the NDSS is protected by the provide information about access to subsidised Privacy Act 1988 (Privacy Act) and the Australian Privacy diabetes -related products, or related information such Principles (APPs) contained in the Privacy Act.

3 As product recalls. What information do we collect? We may disclose your information to the following people or entities: We may collect your personal information if the information is reasonably necessary for administering the NDSS and any of its the Commonwealth as represented by the Department of programs, services, or activities, including providing information, Health, which funds the NDSS, to produce statistical and education, and support services to you or your carer. evaluation reports on the NDSS and for administrative purposes, or for public accountability purposes When personal information is sensitive information (for the Australian Institute of Health and Welfare for inclusion example, health information), it will only be collected if you in the National (insulin-treated) diabetes Register, have consented to that information being collected, or if one cross-checking against the National Death Index, statistical of the other exceptions applies under the APPs.

4 Your personal analysis, to undertake data linkage activities with other information may be collected on forms, such as this form, datasets for health research purposes and to facilitate when you contact the NDSS Helpline, when purchasing NDSS health research projects undertaken by researchers and products or in providing information and services to you or other parties your carer. Commonwealth agencies, researchers, and other parties to facilitate health and other research projects including Personal information that may be collected: data linkage activities, or to plan for the emerging needs of your name, gender, date and country or birth people with diabetes contact details and address, other third parties for the purposes of administering NDSS, Medicare, DVA or Concession card number the NDSS (or providing NDSS programs, services, and details of your guardian or carer activities), including organisations that deliver services on details of your usual GP and other health professional.

5 Our behalf (such as mailing houses), or organisations that provide services to us. Sensitive information that may collected: Once you have registered with the NDSS, you can ask us not diabetes type to contact you about research or state and territory activities. details of the medication and NDSS products you require You will still receive important information about the NDSS or to manage your diabetes product safety issues. main language spoken at home if you are of Aboriginal or Torres Strait Islander origin We are committed to protecting your privacy. The NDSS. Privacy Policy contains information about how you can whether your immediate relatives have had diabetes and access and correct your personal information held by us.

6 How your diabetes is currently managed The policy also explains how to complain about a breach of health services provided to you your privacy and how we deal with privacy complaints. other health information. You can find the NDSS Privacy Policy at It is your choice to provide information to us. However, it will be necessary for us to collect your personal or sensitive information if you would like to access certain NDSS products, education and support services or programs. If you choose For more information regarding how to fill out this form to withhold the information we require, we may not be able to and FAQ's see page 4 of this form.

7 Provide the services you have requested. Have difficulty hearing or speaking? Have difficulty with English? Access TTY on 133 677, Speak and Listen on 1300 555 727 Call the Translating and Interpreting Service (TIS). or Internet Relay at then National on 131 450 and ask for the number enter the number 1800 637 700. 1800 637 700. Version 11 September 2021 NDSSFRM001. diabetes Australia: ABN 47 008 528 461. Person with diabetes 13 Daytime phone number (mobile preferred). The questions in this section are about the person with diabetes . Follow all instructions. 1 Title Given name(s) 14 Alternative phone number 2 Family name 15 Address 3 Do you have a current Medicare card (preferred).

8 Or DVA file number? Suburb State Postcode Yes fill in details and go to 8. 16 In which country were you born? Australia Other (please list). No Go to 4. 17 Are you of Aboriginal or Torres Strait Islander origin? 4 Are you a resident of Belgium, Italy, New Zealand, (tick all boxes that apply). Slovenia, Sweden, the Netherlands or the United Kingdom? No Yes, Aboriginal Yes, Torres Strait Islander Yes Go to 7 No Go to 5 18 Which language do you most often speak at home? 5 Are you a resident of Finland, Malta, Norway or the English Other (please list). Republic of Ireland? Yes Go to 6 No You are not eligible for the NDSS. 19 When were you first diagnosed?

9 6 Are you in Australia on a student visa? (or approximate date). Yes You are not eligible for the NDSS No Go to 7 Day Month Year 7 Please fill in details Passport number 20 Were you living in Australia? Yes Go to 21 No (please list) Go to 22. Country Country of issue Visa expiry 21 Where in Australia were you living? Day Month Year Suburb State Postcode 8 Email (preferred method of contact). 22 By signing here, I am confirming that: I require NDSS products and/or services for the management of 9 Previous Name (optional) my diabetes ; and the information I have provided on this form is true and complete;. and I agree to the collection, use and disclosure of my information for 10 Sex the purposes set out in this form; and Male Female Intersex I understand giving false or misleading information is a serious offence.

10 11 Date of birth Signature Day Month Year If the person named in Q1 and Q2 is Day Month Year under 15 years old, the Carer or guardian . section must also be completed. 12 Do you hold a valid concession card? Yes Fill in details No Go to 13. Type of Concession Health Care Card Pensioner Concession Card Veteran Gold Card Veteran White Card Concession Card Number Expiry Day Month Year Version 11 September 2021 NDSSFRM001. diabetes Australia: ABN 47 008 528 461. Carer or guardian 33 When was GDM diagnosed? This section must be completed by a primary carer or Day Month Year guardian if the person named in Q1 and Q2 is: aged 15 years or under; or 34 Baby's expected date of birth aged 16 years or older and requires a primary carer Day Month Year or guardian.