<p> HE15/16-007 : Appendix A</p><p>Copy: Choose an item.</p><p>Student Deed Poll Given The Australian Capital Territory, the body politic established by section (Territory) to: 7 of the Australian Capital Territory (Self-Government) Act 1988 (Cth) represented by the Health Directorate </p><p>By: [Insert name of Student] of [Insert Student’s address] (You, Your, Yourself, Student)</p><p>Background A The Territory administers the ACT Health Vacation Study Program (Program) which is open to tertiary students studying a medical or allied health discipline. The Program offers such students the opportunity to attend a 6 week placement to undertake a research project. B The Territory has offered you a Placement to undertake the Research Project as part of the Program. C You are entering into this Deed Poll for the purpose of covenanting in favour of the Territory to undertake the Placement and Research Project on the terms of this Deed Poll.</p><p>Definitions In this Deed Poll: “Confidential Information” means any information that is by its nature confidential or is designated by the Territory as confidential or You ought to know is confidential, and includes: (a) information concerning the clinical processes and policies, guidelines, procedures, strategies, operations, financial arrangements or affairs of the Territory; (b) the terms of this Deed Poll; (c) information which identifies or relates to patients of the Territory; (d) Personal Information; (e) Know-How of the Territory; and (f) all other material including but not limited to books, documents, information, computer software, equipment and data stored by any means disclosed or made available by the Territory to You in connection with undertaking the Research Project; but does not include: (g) information that is publicly known other than as a result of Your breach of this Deed Poll; and (h) information lawfully in Your possession through a source other than the Territory. “Document” includes, but is not limited to: (a) any paper or other material on which there is writing; (b) any paper or other material on which there are marks, figures, symbols or perforations, having a meaning for a person qualified to interpret them; and (c) any disk, computer file, tape, or other article or any material from which sounds, images, writings or messages are capable of being produced or reproduced (with or without the aid of another article or device).</p><p>1 “Facility” means a public sector hospital; community based health service or other facility or service run by the Territory. “Information Privacy Act” means the Information Privacy Act 2014 (ACT). “ Intellectual Property” includes all copyright and neighbouring rights, all rights in relation to inventions (including patent rights), registered and unregistered trademarks (including service marks), registered designs, circuit layouts and confidential information. “ Know-How” means unpatented technical and other information which is not in the public domain including ideas, concepts, inventions, discoveries, data, formulae, specifications, procedures for experiments and tests and results of experimentation and testing, results of research or development including laboratory records, clinical trial data, case report forms, data analysis, and information contained in submissions to and information from ethical committees and regulatory authorities. "Personal Information" means personal information as defined in section 8 of the Information Privacy Act, namely, information or an opinion about an identified individual or an individual who is reasonably identifiable: (a) whether the information is true or not; and (b) whether the information or opinion is recorded in a material form or not, but does not include personal health information (as defined in the Health Records (Privacy and Access) Act 1997 about the individual). “Placement” means Your attendance at a Facility for the purposes of conducting the Research Project for a period of 6 weeks. “Research Project” means the research project described in Your ACT Health Vacation Study Program Offer Letter provided to you on or about the date of this Deed Poll. “TPPs” means the Territory Privacy Principles provided for in section 13, and set out in Schedule 1, of the Information Privacy Act. “TPP Code” means a code of practice about information privacy that binds the agency that engages You to undertake the Placement. </p><p>Your undertakings By this Deed Poll, You covenant for the benefit of the Territory as follows: 1. You must undertake and complete the Research Project diligently and to the Territory’s reasonable satisfaction by the end of the Placement, and otherwise in accordance with this Deed Poll; 2. at the end of Your Placement, You must provide a comprehensive report to the Territory’s satisfaction setting out the activities You have undertaken as part of the Research Project, the Research Project objectives and any research findings or observations You have made as a result of Your undertaking the Research Project (Research Project Report); 3. You will undertake an appropriate orientation process at a Facility and make Yourself aware of all guidelines, policies and procedures applicable to You while on Placement; 4. in undertaking the Research Project, You may be required to observe Territory patients but You must not have any physical contact with any patient, unless otherwise instructed by the Territory; 5. You will not communicate to any person any information obtained during Your attendance at a Facility, which could identify an individual who is receiving or has received a public sector health service, unless: (a) You are compelled or authorised to do so by law; (b) the individual consents to the disclosure and only subject to the express terms of that consent; or (c) the disclosure is required for further treatment of the individual; 6. Intellectual Property: (a) You create in the course of undertaking the Research Project; and (b) in the Research Project Report will vest upon its creation in the Territory and You may use the Territory’s Intellectual Property only 2 for the purpose of undertaking the Research Project and only for the duration of Your Placement;.; 7. if You wish to use the Territory’s Intellectual Property (for example any Document, Confidential Information or Know How used or developed during Your Placement, or the Research Project Report), for any purpose after the Placement, You must first request the Territory’s approval in writing. The Territory may approve Your request or not in its absolute discretion and may impose conditions including requiring you to acknowledge the Territory’s ownership of the Intellectual Property in a particular form; 8. You will undertake a national criminal record check prior to commencing Your Placement in a Facility; 9. You will ensure You are registered under the Working with Vulnerable People (Background Checking) Act 2011 (ACT) if undertaking Your Research Project requires You to be registered under that Act; 10. whilst on Placement, You will not be an employee of the Territory; 11. Subject at all times to clause 16 You will use all Territory materials including Documents, Confidential Information and Know How strictly in accordance with any conditions or restrictions communicated to You by Territory staff. At the end of the Placement, You will return all such Territory materials to the Territory; 12. You will comply with all lawful directions of Territory staff and will carry out only those activities, procedures and/or acts required for the purposes of Your Placement and the Research Project under the direction of Territory staff; 13. You will comply with all relevant policies, procedures, guidelines and directives of the Territory whilst on Placement, including procedures regarding: (a) immunisation and infection control; (b) work health and safety, manual handling, working with hazardous substances and dangerous goods; (c) dress requirements and identification; (d) access to, and use of, Territory information and technology systems; and (e) any other Territory or Facility policy or guideline. 14. You will comply with the Territory’s applicable standards of conduct while on the Territory’s premises and when having contact with clients and personnel of the Territory. Failure to do so may lead to your Placement being suspended or terminated. 15. You acknowledge that this Deed Poll may be relied on and enforced by the Territory in accordance with its terms even though the Territory is not a party to this Deed Poll.</p><p>Confidential Information of the Territory 16. You agree to use and disclose the Territory’s Confidential Information only for the following purposes: (a) attending the Placement and performing the Research Project under this Deed Poll; and (b) as otherwise required or authorised by law. 17. Except as provided for in paragraph 16, You must: (a) not disclose to any third party any of the Territory’s Confidential Information except as authorised by the Territory or as required by law; (b) not make copies or duplicates of the Territory’s Confidential Information except for the purposes of the Placement or the Research Project; (c) do all things necessary to preserve the confidentiality the Terriory’s Confidential Information and ensure the Territory’s Confidential Information that is accessible to You while on Placement or undertaking the Research Project, is not accessed, published or communicated in any way that is not authorised by the Territory; (d) notify the Territory if You become aware that a disclosure of Confidential Information may be required by law, or that an unauthorised disclosure of Confidential Information has occurred; 3 (e) ensure, in using the Territory’s Confidential Information, that patient confidentiality and confidentiality of patient and deceased person’s health records are strictly maintained and not disclosed except as other provided by the Health Records (Privacy and Access) Act 1998 (ACT); and (f) in respect of any Personal Information held in connection with this Deed Poll: (i) comply with the TPPs and any applicable TPP Code and not act or engage in a practice that breaches a TPP or a TPP Code; and (ii) co-operate with any reasonable requests or directions of the Territory arising directly from, or in connection with, the exercise of the functions of the information privacy commissioner under the Information Privacy Act. 18. At the end of the Placement, at the written request of the Territory, or upon any breach of this Deed Poll, the Territory may demand that You return to the Territory, destroy or erase any of the Territory’s Confidential Information in Your possession, and You must comply with the demand immediately.</p><p>Your Personal Information 19. The Territory will collect Personal Information about You for purposes associated with the Placement. The Territory’s information privacy obligations are set out in the Information Privacy Act. 20. You may request a copy of the ACT Health Directorate privacy policy which details how You may request access to Personal Information the Territory holds about You. 21. The Territory will disclose information it holds about You only with Your consent or where disclosure is required or authorised by or under law, or in accordance with the “territory privacy principles” contained in the Information Privacy Act, except that the Territory may disclose information and opinions about You to your tertiary institution for purposes associated with the Placement.</p><p>Signed as a Deed Poll</p><p>………………………………..……… ……………..………………………………….. Signature of Student Name of Student in full</p><p>..……………………………...……….. …………….………………………………….. Signature of Witness Name of Witness in full</p><p>…………………………..…..……….. Date of execution</p><p>4</p>