Updated December 2017 Page 2 of 2 Workplace ID SFU600
Terms of participation – PLEASE READ before signing this form
I acknowledge that I have read, understand, and agree to the above terms and wish to register for the program.
Please return completed form to Quitline
Email: 13QUIT@health.qld.gov.au Fax: 07 3259 8217
1. Eligible participants are entitled to one course of NRT (up to 12 weeks) for their personal use only. A clinical assessment for the provision of NRT will be undertaken
during the first contact. The participant agrees NRT will be used only as directed will not give or share NRT with another person.
2. In the case of partner or family member participating, Quitline will maintain confidentiality and will NOT disclose any information between participating
3. Employees may wish to check with their financial advisor that the receipt of NRT does not have Fringe Benefit Tax implications.
4. Quitline will display as a blocked number when attempting to call participants.
5. Quitline will attempt to contact participants at their nominated day and time. If contact is unsuccessful the service will leave a message unless specified above.
Personal information, including sensitive information, collected by the Department of Health is handled in accordance with the Information Privacy Act 2009. The
purpose of this form is so that patients may be referred to the Quitline service for information, advice and assistance. All personal information will be securely stored
and only accessible by authorised officers of the department. Demographical information, such as gender, age group, suburb and cultural background may be used for
our statistics, but will not include any identifiable information. Personal information will not be disclosed to third parties without consent, unless required or
authorised by law. For further information, including an individual's right to access their own personal information, please see our website
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