Smoke-Free JCU
Registration Form
Updated December 2017 Page 1 of 2
Workplace ID SFU600
Note: You must be a current smoker to participate in the pr
ogram.
All fields below must be completed in order to process registration.
Given names:
Surname:
Gender:
Male Female
Date of birth:
Postal address (This is where the nicotine replacement therapy will be posted)
Postcode
Telephone contact numbers:
Mobile: Work: Home:
If Quitline is unable to contact you, a message will be left on your phone. If you do not want Quitline to leave a message, please indicate here
WHEN QUITLINE CALLS, IT WILL APPEAR AS A BLOCKED NUMBER ON YOUR PHONE.
Email address:
Indigenous status: (select one only)
Aboriginal
and Torres Strait Islander
Aboriginal but not T
orres Strait Islander
Torres Strait Islander but not Aboriginal
Neither
Would you like to speak to an Aboriginal and/or Torres Strait Islander Quitline staff member?
Yes No
JCU Site:
Please select your preferred time on each day to receive a call from Quitline (ONE TIME PER DAY ONLY):
Monday
ALL DAY
N/A
7am-8:30am 8:30am-1pm 1pm-5:30pm 5:30pm-8:30pm
8:30pm-10pm
Tuesday
N/A
7am-8:30am 8:30am-1pm 1pm-5:30pm 5:30pm-8:30pm
8:30pm-10pm
Wednesday
N/A
7am-8:30am 8:30am-1pm 1pm-5:30pm 5:30pm-8:30pm
8:30pm-10pm
Thursday
N/A
7am-8:30am 8:30am-1pm 1pm-5:30pm 5:30pm-8:30pm
8:30pm-10pm
Friday
N/A
7am-8:30am 8:30am-1pm 1pm-5:30pm 5:30pm-8:30pm
8:30pm-10pm
Saturday
N/A
7am-8:30am 8:30am-1pm 1pm-5:30pm 5:30pm-8:30pm
8:30pm-10pm
Sunday
N/A
7am-8:30am 8:30am-1pm 1pm-5:30pm 5:30pm-8:30pm
8:30pm-10pm
Continue to next page
ALL DAY
ALL DAY
ALL DAY
ALL DAY
ALL DAY
ALL DAY
Occupation Group (please tick the box that best suits your current occupation group)
Professional
Mackay
Mount Isa
Townsville
Brisbane
Thursday Island
Cairns
Academic
Research
Other
Registering as:
Employee
Contractor Partner/Spouse/Family member*
If registering as a Partner/Spouse/Family Member please write down the name of eligible James Cook University employee registered on the program:
*Available only to the Partner/Spouse/Family Member of an
employee registered on the program
DO NOT COMPLETE the following two sections if you are registering as a Partner/Spouse/Family member
Smoke-free JCU
Registration Form
Updated December 2017 Page 2 of 2 Workplace ID SFU600
Terms of participation PLEASE READ before signing this form
Participant acknowledgement
I acknowledge that I have read, understand, and agree to the above terms and wish to register for the program.
Signature: Date:
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
individuals.
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.
Privacy notice
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
(https://www.health.qld.gov.au/system-governance/records-privacy)
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