Newborn Screening Center - Northern Luzon

Mariano Marcos Memorial Hospital and Medical Center

4F/5F Laboratory Building, Brgy. 6 - San Julian, Batac City, Ilocos Norte 2906
Telefax No.: (077) 677 3161  Telephone No.: (077) 600 8088
Email: nscnorthernluzon@gmail.com

DATA PROTECTION POLICY

Newborn Screening Center – Northern Luzon (NSC-NL) - Mariano Marcos

Memorial Hospital and Medical Center (MMMHMC), recognizes the need to ensure the
welfare and safety of all newborn patients and their parents taking part in any activities
associated with our organization.

In accordance with our data protection policy, we will not permit photographs, video
or other images of newborn patients to be taken without the consent of the parents. As
the newborn patients and their parents will be taking part in Expanded Newborn
Screening Social Media Advocacy Campaign, we would like to ask for your consent to
take photographs/videos of the event or activity that may contain images of your child. It
is likely that these images may be used as:

• a record of the advocacy activity

• in a written evaluation report of the activity or event that will be viewed by
NSC-NL
• publicity material for program advocacy purposes on leaflets / websites /
magazines

The Newborn Screening Center – Northern Luzon (NSC-NL) will take all steps to
ensure these images are used solely for the purposes they are intended. If you become
aware that these images are being used inappropriately you should inform Newborn
Screening Center – Northern Luzon (NSC-NL) immediately.

We would be grateful if you would return this form to

___________________________ (NBS Coordinator) by the ______________ (Date).

CONSENT FORM

I, ___________________________________ (Name of Parent) give my consent

for the photo / video / voice recording of my infant to appear in NSC-NL Facebook Page
taken by ________________________________ (Name of NBS Coordinator) from
________________________________ (Name of Newborn Screening Facility), and
hereby authorize release of such to Newborn Screening Center – Northern Luzon (NSC-
NL).

I confirm that I: (please tick boxes to confirm)

 have seen the photo, image, text or other material about me/the patient
 am legally entitled to give this consent.

I understand the following:

Expanded Newborn Screening is now covered by Philhealth!

 Newborn Screening Center - Northern Luzon
Mariano Marcos Memorial Hospital and Medical Center
4F/5F Laboratory Building, Brgy. 6 - San Julian, Batac City, Ilocos Norte 2906
Telefax No.: (077) 677 3161  Telephone No.: (077) 600 8088
Email: nscnorthernluzon@gmail.com

1. The photo / video / voice recording will be published without my/the patient’s
name attached, however I understand that complete anonymity cannot be
guaranteed. It is possible that somebody somewhere - for example, somebody
who looked after me/the patient or a relative - may recognise me/the patient.
2. The photo / video / voice recording may be linked to from social media and/or
used in other promotional activities. Once published, the article will be placed
on a NSC-NL Facebook Page and may also be available on other websites;
3. I/the patient will not receive any financial benefit from publication of the article.
4. I can revoke my consent at any time before publication, but once the photo /
video / voice recording has been published on the NSC-NL Facebook Page, I
will have to inform _________________________________________ (Name
of Newborn Screening Facility) and/or NSC-NL to remove the published post
5. This consent form will be retained securely and in confidence by NSC-NL and
_________________________________________ (Name of Newborn
Screening Facility) in accordance with the law, for no longer than necessary.
6. I consent _______________________________________ (Name of Newborn
Screening Facility) and/or NSC-NL for storing my contact details for the sole
purpose of contacting me, if necessary, in the future.
7. Where this consent relates to the Expanded Newborn Screening Social Media
Advocacy Campaign, I have the opportunity to comment on the purpose of the
said activity and finds it helpful to other parents.

Signed : ________________________________

Print name : ________________________________

Address : ________________________________

Email : ________________________________

Cellphone No : ________________________________

Expanded Newborn Screening is now covered by Philhealth!