Know Your Numbers

Personal Information

First Name*

Middle Name

Last Name*

Sex

Male

Female

DOB

TRN

Passport Number

Electoral ID

Phone Number

Address

Parish

Community Settlement

Street number

Street name

Street Address Line 2

Post Office Name

Screening

I AGREE TO A FOLLOW UP TELEPHONE CALL FROM THE MINISTRY OF HEALTH AND WELLNESS TO PARTICIPATE IN AN EVALUATION OF THE ‘KNOW YOUR NUMBERS’ COMMUNITY HEALTH SCREENING CAMPAIGN.*

Yes

National Community Health Screening

‘Know Your Numbers’ Campaign

INFORMED CONSENT FORM

COMMUNITY SCREENING AND FOLLOW-UP EVALUATION

The Community Screening for Non-Communicable Diseases such as Diabetes and Hypertension, will collect your personal data (including your name, address and date of birth) and your health data (including your personal and family history of these conditions, your blood sugar, blood pressure and blood cholesterol) for the purpose of informing you of your health status. These data are shared with the health care team at the place where you will go for a follow up visit if your results are abnormal.

In addition, as a part of its monitoring and evaluation function, the Ministry of Health and Wellness (MoHW ) will evaluate the National Mobile Health Screening campaign. A component of this evaluation is an interview with individuals referred to a health centre or hospital for further treatment. The purpose of the evaluation is to gather information about the healthcare services you accessed since being screened and will focus on areas such as:

Whether you accessed care based on the referral;
where you obtained treatment, that is, at your local health Centre, a private health facility or at the hospital;
the type of treatment you received;
and whether you received health education information about your condition.

Your participation in this evaluation is completely voluntary, and you may withdraw at any time. You will be contacted by phone, by a Monitoring and Evaluation Analyst from the MoHW. You will be asked a series of short answer questions during these phone calls. The MoHW will ensure the strict confidentiality of all information shared. The phone call will be recorded for data collection purposes only.

If you have any questions, concerns, or issues, you may contact Mr. Harold Daniel, Director, Policy Monitoring & Evaluation; Policy Planning and Development Division by email: haroldshane.daniel@moh.gov.jm or by phone at: 876-633-8286

I AGREE TO THE PROCESSING OF MY PERSONAL AND HEALTH DATA FOR CHRONIC DISEASES COMMUNITY SCREENING AND FOLLOW UP REFERRAL AS NEEDED.

Personal Information

Address

Screening

Screening History

Family History

Select all that apply

Personal Medical History

Select all that apply

Other Risk Behaviour