PO Box 1700 STN CSC
Victoria, BC V8W 2Y2
Tel (250) 721-7954 Fax 721-6231
Email:
Collection, Use and Disclosure of Personal Information
Introduction:
The School of Nursing at the University of Victoria offers a program of studies leading to a Bachelor of Science in Nursing (BSN) degree for students continuing from our College-University Transfer BSN Program partner sites. In addition, the Post-Diploma Distance Program is offered to post-diploma registered nurses who complete the BSN degree by distance education.
Throughout your program, the university will require the collection, use and disclosure of personal information. Therefore, this form covers the collection, use and disclosure of your personal information necessary to provide you with educational and related services throughout your BSN degree program.
As initial acceptance into the College-University Transfer BSN program takes place at the college or university-college level, it is necessary that documentation and information on the progress of students in their academic program and the information gained from the students’ criminal record check process be shared between the originating college or university-college and the University of Victoria.
This form provides the necessary notice for the collection of personal information directly from you; your authorization for indirect collection; your consent for your current educational institution to disclose the necessary personal information to the UVic School of Nursing; and your consent to disclose your personal information to third parties such as your practice placements.
Collection Notice:
The University of Victoria, School of Nursing is committed to treating personal information in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA) and the university’s privacy policy. The collection of personal information on forms, in student profiles and in resumes by the School of Nursing is in accordance with section 26 of the FIPPA and the University Act. The School of Nursing uses the personal information for the purposes of providing educational and related services. The faculty and staff of the School of Nursing use the personal information as required by the performance of their duties. The School of Nursing uses the personal information for the purposes of planning or evaluating the BSN program. For a detailed listing of the collection purposes see: http://www.uvic.ca/universitysecretary/assets/docs/policies/Schedule%20A,%20Procedures%20for%20the%20Management%20of%20Personal%20Information.pdf.
Should you have any questions concerning your personal information, please contact the access and privacy office at .
Authorization to Collect and Consent to Disclose:
(For the College-University Transfer BSN program only)
By signing this form, you authorize the UVic School of Nursing to collect from your current and/or past educational institution and agree to permit that institution to disclose to the UVic School of Nursing:
1. Any or all criminal records checks made within the last 5 years submitted for the purpose of completing the BSN;
2. Your practice appraisal forms undertaken in Semesters 1—5;
3. Information about your progression as a student in years 1-4; and
4. Information regarding any field schools or international practice placements you have or will participate in.
Consent to Disclose:
By signing this form, you agree that the UVic School of Nursing has permission to disclose to:
1. Practice agencies your personal information (name, mailing address, email address, phone number, learning needs/goals, nursing practice experience, photo from UVic student ID card*, expected graduation date, and the results of any criminal records check(s) for the purpose of locating, coordinating and supporting an appropriate placement (clinical practica, fieldwork, or preceptorship) experience for you within those agencies.
2. Individuals as necessary to respond to an emergency that threatens the life, health or security of an individual.
3. The Department of International Affairs your personal information necessary to register in the “Registration of Canadians Abroad Service” if you participate in field schools or exchanges outside of Canada.
4. UVic student societies for the purpose of administering the Health Plan, UPass Plan and the administration of the student society.
5. Professional organizations for membership and licensing purposes.
*For the use of the VIHA Proximity (security) Access card
Please sign below to indicate your agreement to the above.
Signature
Student’s Name
Date (dd/mm/yy)
Please note: This consent is valid for the period of your BSN degree program.
Bill Trott – Chief Privacy Officer
Approved 27/08/2015 June 2015Page 1