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Lees Medical Practice

Athens Way, Lees, Oldham, OL4 3BP

Telephone: 0161 652 1285

gmicb-old.leesmedicalpractice@nhs.net

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PATIENT NOTICE Privacy Notice for Patients

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. The test is a list of eight situations in which you rate your tendency to become sleepy on a scale of 0, no chance of dozing, to 3, high chance of dozing. When you finish the test, add up the values of your responses. Your total score is based on a scale of 0 to 24. The scale estimates whether you are experiencing excessive sleepiness that possibly requires medical attention.

Your Name(Required)

Your Date of Birth(Required)

How Sleepy Are You?

How likely are you to doze off or fall asleep in the following situations? You should rate your chances of dozing off, not just feeling tired. Even if you have not done some of these things recently try to determine how they would have affected you.

Sitting and reading(Required)

Watching TV(Required)

Sitting inactive in a public place (e.g., a theater or a meeting)(Required)

As a passenger in a car for an hour without a break(Required)

Lying down to rest in the afternoon when circumstances permit(Required)

Sitting and talking to someone(Required)

Sitting quietly after a lunch without alcohol(Required)

In a car, while stopped for a few minutes in traffic(Required)

Your score(Required)

Interpretation:

0-7:It is unlikely that you are abnormally sleepy.
8-9:You have an average amount of daytime sleepiness.
10-15:You may be excessively sleepy depending on the situation. You may want to consider seeking medical attention.
16-24:You are excessively sleepy and should consider seeking medical attention.

44299

Opening Times

Monday
08:00am to 06:30pm
Tuesday
08:00am to 06:30pm
Wednesday
08:00am to 06:30pm
Thursday
08:00am to 06:30pm
Friday
08:00am to 06:30pm
Saturday
CLOSED
Sunday
CLOSED

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Introduction

In accordance with the General Data Protection Regulation, patients (data subjects) have the right to access their data and any supplementary information held by Lees Medical Practice. This is commonly known as a data subject access request (DSAR). Data subjects have a right to receive: • Confirmation that their data is being processed • Access to their personal data • Access to any other supplementary information held about them Options for access As of April 2016, organisations have been obliged to allow patients access to their health record online. This service will enable the patient to view coded information held in their health record. Prior to accessing this information, you will have to visit the organisation and undertake an identity check before being granted access to your records. In addition, you can make a request to be provided with copies of your health record. To do so, you must submit a Data Subject Access Request (DSAR) form. This can be submitted electronically and the DSAR form is available on the organisation website. Alternatively, a paper copy of the DSAR is available from reception. You will need to submit the form online or return the completed paper copy of the DSAR to the organisation. Patients do not have to pay a fee for copies of their records. Time frame Once the DSAR form is submitted, Lees Medical Practice will aim to process the request within 21 days; however, this may not always be possible. The maximum time permitted to process DSARs is one calendar month. Exemptions There may be occasions when the data controller will withhold information kept in the health record, particularly if the disclosure of such information is likely to cause undue stress or harm to you or any other person. Data controller At Lees Medical Practice the data controller is Julie Rowe and should you have any questions relating to accessing your medical records, please ask to discuss this with the named data controller.

Application Form for Access to Health Records

APPLICATION FORM FOR ACCESS TO HEALTH RECORDS in accordance with the General Data Protection Regulation (GDPR) DATA SUBJECT ACCESS REQUEST

Section 1: Patient details

Your Name(Required)

Title (i.e. Mr, Mrs, Ms, Dr) First Middle Last

Your Address(Required)

Street Address Address Line 2 City Postcode

Preferred Method of Contact

Your Email Address

Email Address Confirm email address

Your Phone(Required)

NHS Number (If known)

Hospital Number (If known)

Section 2: Record requested

The more specific you can be, the easier it is for us to quickly provide you with the records requested, for example records in respect of treatment received (e.g. for leg injury following a car accident)

Section 3: Details and declaration of applicant

Please enter the details of the applicant if different from Section 1

Name

Title (Mr, Mrs, Ms, Dr) First Last

Address

Street Address Address Line 2 City Postcode

Telephone number

Section 4: Declaration

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the GDPR.

Please select:

I am the patient

I have been asked to act by the patient and attach the patient’s written authorisation

I have full parental responsibility for the patient and the patient is under the age of 18 and: (a) has consented to my making this request, or (b) is incapable of understanding the request

I have been appointed by the court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so

I am acting in loco parentis and the patient is incapable of understanding the request

I am the deceased person’s personal representative and attach confirmation of my appointment (grant of probate/letters of administration)

I have written, and witnessed, consent from the deceased person’s personal representative and attach proof of appointment

I have a claim arising from the person’s death (please state details below)

Signature

Date

You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.

Section 5: Proof of identity

Please indicate how proof of ID has been confirmed. Please select ‘A’ or ‘B’:

5A – Evidence

Evidence of the patient’s and/or the patient’s representative identity will be required. Please attach copies of the required documentation to this application form. Examples of required documentation are:

A: An individual applying for his/her own records. One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc. B: Someone applying on behalf of an individual (Representative). One item showing proof of the patient’s identity and one item showing proof of the representative’s identity (see examples in ‘A’ above) C: Person with parental responsibility applying on behalf of a child. Copy of birth certificate of child and copy of correspondence addressed to person with parental responsibility relating to the patient D:Power of Attorney/Agent applying on behalf of an individual. Copy of a court order authorising Power of Attorney/Agent plus proof of the patient’s identity (see examples in ‘A’ above)

5B: Countersignature

This section is to be completed by someone (other than a member of your family) who can vouch for your identity. This section may be completed if 4A cannot be fulfilled.

I (insert full name)

First Last

Certify that the applicant (insert name)

First Last

has been known to me personally as .......................................... for ..........................years (insert in what capacity, e.g. employee, client, patient, relative etc.) and that I have witnessed the signing of the above declaration.

I am happy to be contacted if further information is required to support the identity of the applicant as required.

First Last

Signature

Date

Profession

Profession

Address

Street Address Address Line 2 City Postcode

Phone

Additional notes

Before returning this form, please ensure that you have: a) Signed and dated this form b) Enclosed proof of your identity or alternatively confirmed your identity by a countersignature c) Enclosed documentation to support your request (if applying for another person’s records) Incomplete applications will be returned. Please therefore ensure you have the correct documentation before returning the form.

Phone

This field is for validation purposes and should be left unchanged.

92303