Data Extraction Consent Form

DATA EXTRACTION CONSENT FORM

Pharmacy name: ______

RAMS Number: ______

I, ______in my capacity as ______

of abovementioned pharmacy, hereby authorises ______(pharmacy software vendor) to extract the required electronic data (‘Data’**) from my systems for use and processing by the Independent Community Pharmacy Association NPC (‘ICPA’), as the responsible party as contemplated in the Protection of Personal Information Act, Act 4 of 2014 (‘the Act’) situated at Unit 3, Mews 2, Rosmead Centre, 67 Rosmead Avenue, Kenilworth, Cape Town, possibly in conjunction with a third party appointed by the ICPA to assimilate the data. I understand that the Data will be converted and standardised prior to its use in reports and services so that it cannot be identifiable to any one site.

By signing this consent form, I expressly agree to the collection, collation, processing, disclosure, retention and/or use of the Data, which may include, inter alia, research, commercial analysis for medical aid negotiations, disease management and legislative decision making, whether in electronic form or any other form. I acknowledge that my consent so provided is given freely and voluntarily and I am under no obligation to provide this consent should I choose not to do so.

I acknowledge that I am entitled to request information at any time about the Data collected and may further request that the Data be corrected, deleted or blocked, in accordance with the relevant provisions of the Act. I may also object to the processing and use of the Data for marketing and market research purposes at any time. Where I suspect any interference with the protection of the Data, I further understand that I may submit a complaint to the Information Regulator as contemplated in the Act. Furthermore, I expressly agree that the Data may be transferred, whether in electronic form or any other form, to a service provider which may be situated in a jurisdiction that does not have the same level of protection in respect of the processing of personal information, as is provided for in the Act. I understand that I may terminate this authorisation by providing one calendar month’s notice in writing, to the above address and that my data will be handled with the strictest confidentiality at all times.

I further confirm that I am duly authorized to sign this consent form.

Signature: ______

This consent form was duly signed at ______this ____ day of ______2016.

Physical address of pharmacy:Postal address of pharmacy:Pharmacy contact details:

______Telephone: ______

______Fax number: ______

______Email address: ______

______Website: ______