Getting the Balance Right Registration

Getting the Balance Right Registration

About Getting The Balance Right

Thank you for your interest in Getting The Balance Right. Getting The Balance Right is MS Ireland's regional physiotherapy service. This service is available nationwide and you do not need to be a member of MS Ireland to participate. Getting the Balance Right programmes are made possible by the great fundraising done by our branches and through grants like the national lottery (amongst other sources)

How is my information managed?

This form will help us learn about you and what you would like to gain from this programme. Your information is input directly into MS Ireland's SalesForce systems and is only available to the physiotherapy team that delivers Getting The Balance Right. You can decide against integrating your information with MS Ireland's membership database if you wish. However, to avoid unnecessary duplication within our database, your name email and date of birth only will be visible to all MSIreland staff. If you are already a member of MSIreland, your regional office will be able to see that you are taking part in Getting The Balance Right. They will not be able to see the information you enter.

To help us find the programme that best matches your needs, please provide enter the following details

Your First Name

Your Surname

Preferred Phone

Mobile PhoneFixed-line Phone

Phone

Mobile Phone

Email Address

Date of Birth

Name of referrer

Name and email address of referrer

Are you a member of MS Ireland or do you avail of support from a branch or region?

YesNo

Would you like to be added to MS Ireland's members database?

YesNo

Do you use a walking aid?

YesNo

Have you had a fall recently?

YesNo

Have you had any near misses, or almost fall, or catch yourself before you fall?

YesNo

What is your preferred class time

MorningAfternoonEvening

GDPR and Consent - In order for Getting The Balance Right project to comply with current General Data Protection Regulations (GDPR) we are required to obtain your formal consent to gather and use information about you. Under this regulation Getting The Balance Right and MS Ireland must adhere to the following:

· Valid consent must be explicit for the data collected and the purposes the data is used for

· The consent does not imply consent forever

· The data must only be used for the purpose it was initially intended for and no other

The first part of the data we collect will be used to ensure your safety and suitability to participate in Getting The Balance Right. (Medical history, Medication list and Physical Activity Readiness Questionnaire). This data will be collected over the Zoom assessment or in person and is stored on our secure online servers and encrypted laptops.

The other data we gather will be during an in-person discussion or an individual consultation using Zoom for healthcare as well. The questionnaires and information gathered will be used to evaluate the effects of the programme or to tailor the programme for you. You will complete the same questionnaires before and after the programme. We will also record information about how you are completing the programmes.

Your data will be stored on our secure Salesforce platform for 7 years after you finish the programme. Only the Getting The Balance Right physiotherapy team will have access to your individual data.

The data in the questionnaires you complete before and after the programmes will be entered into spreadsheets and analysed as group averages with no sharing of individual data. The aggregated (and hence anonymous) data from all participants will be used in project reports or in presentations to professional groups or to health funders. We may ask if we can use your information for a case study and you can choose if this is anonymous.

Therefore, Getting The Balance Right requires you to consent to the following:

I consent to the Getting The Balance Right physiotherapy team collecting, processing, analysing, and storing the data associated with providing me with an exercise programme or treatment

I consent to the Getting The Balance Right physiotherapy team creating and updating a file with my data

I consent to be assessed and treated by the physiotherapist or exercise personnel either in-person or using Zoom for healthcare

Yes - I consent to the GDPR policy outlined aboveNo - I do not consent to the GDPR policy outlined above

Thank you for completing this form which will be reviewed shortly by the Getting The Balance Right physiotherapy team .

If you have queries please contact either; Susan: SusanC@ms-society.ie 086-036-4109 Jack: JackM@ms-society.ie 086-074-9628

If you have any special requirements, concerns or requests, you may note them below:

Contact Information