I have discussed this consent form with my employer. I understand that any data gathered will be maintained within a confidential case file, accessible only to those directly involved in coordinating and overseeing my return to work process. I am aware that I retain the right to modify or retract my consent at any point by informing CrewCard.

I understand that my employer will:

• only collect personal and health information that is relevant and necessary to manage my recovery at work and facilitate the worker’s compensation claim
• only use and disclose information for the purpose for which it was collected
• keep any information collected separately from my other personnel records
• take reasonable steps to protect my information by ensuring it is stored securely, kept no longer than necessary and disposed of appropriately
• allow me to access my information without unreasonable delay unless providing access would be unlawful or pose a serious threat to another person’s life or health.