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APPLICATION FOR TRAINING STAY IN ICS/GSS CENTERS LLEIDA, PIRINEU I ARAN

VOLUNTEER

Only volunteers from those centers with which the stay has been confirmed can fill out ths form.

All volunteer requests must be validated by the centres, befoer the start of the service.

Volunteer

DNI/NIE/PASSPORT (*):

1st Surname (*):

2on Surname :

Name (*):

“If you do not have a Catalan health card, you can request it at https://salut.gencat.cat/pls/rca/rcapktsi_COVID.SOLICITAR_TSI_FORM”

Email (*):

Date of Birth (*):

Telephone (*):

Association

Apartment/Service

Photography

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**ACCEPTANCE OF THE BASES (*)**

By submitting this application I agree to:

Turn learning into concrete actions towards the patients and professionals of my team, with the aim of participating in its continuous improvement.

Join the center on the agreed date, meet the scheduled hours and respect the rules set by the center.

Have the necessary health coverage in accordance with the established legal requirements and maintain it throughout the duration of the training stays.

Inform by email the tutor of the training center and the health center well in advance of foreseeable absences and on the same day of unforeseeable ones.

Respect at all times the regulations governing the protection of personal data (Seventeenth Additional Provision of Organic Law 3/2018, of December 5, on the protection of personal data and guarantee of digital rights -LOPDGDD-, in relation to the article 9.2 of Regulation (EU) 2016/679 of the Parliament and of the Council, of April 27, 2016, regarding the protection of natural persons with regard to the processing of personal data and the free circulation of these data and by the repealing Directive 95/46/EC -General Data Protection Regulation-). In relation to the foregoing, I am aware that the Penal Code classifies as a crime punishable by imprisonment whoever, without being authorized, accesses personal health data that is registered in files or computer, electronic or telematic media, or in any type of file or public or private record. The dissemination, disclosure and transfer to third parties of personal health data are also punished with a prison sentence.

Given the health emergency situation caused by the SARS-CoV-2 coronavirus and the exceptional measures decreed by the Government of the Generalitat, to scrupulously comply with the protection and action measures of the training post, to comply with all regulations of ICS and GSS indicated to guarantee the protection, hygiene and safety measures related to the health emergency situation caused by the SARS-CoV-2 coronavirus.

In case of breach of the above obligations, I accept the automatic and immediate termination of my training stay.

I consent that the Catalan Institute of Health and Management of Health Services, as appropriate, treat my data in order to manage the institutional relationship derived from the sending of information and publications, calls for minutes and other activities, work and presentations, subscriptions, and other types of communications derived from own actions. Basic information on data protection Identification of the treatment: 'Send information and inscriptions of Management of Health Services' Responsible for the treatment: Direcció Gerència. Management of health services. Avenida Rovira Roure 44, 25198 Lleida Purpose: Manage the institutional relationship of Health Services Management derived from sending information and publications, calls for minutes and other activities, collaborations and presentations, subscriptions, and other types of communications derived from Management actions. of Health Services 'Sending of information and inscriptions of the Catalan Institute of Health' Responsible for the treatment: Management Department. Catalan Institute of Health. Avda. Rovira Roure, 80 25198 Lleida 25198 Lleida Purpose: Manage the institutional relationship of the Catalan Health Service derived from sending information and publications, calls for minutes and other activities, collaborations and presentations, subscriptions, and other types of communications derived from actions of the Catalan Institute of Health. Legitimation: Consent of the interested person. The person concerned can withdraw consent at any time. Recipients: data communications are foreseen to the departments of the Generalitat and related entities that depend, in accordance with their competences, for the management of the different public services and in official institutions and bodies and in public administrations. The data will also be communicated to those in charge of processing who act on behalf of the data controller. Rights of interested persons: you can exercise your rights of access, rectification, deletion, opposition to treatment, right to be forgotten, right to data portability and limitation request, by submitting a letter addressed to the Management Department (Management of Health Services Avenida Rovira Roure 44, 25198 Lleida / Catalan Institute of Health Avda. /contacte' target='_blank'>www.gss.cat/ca/contacte and www.icslleida.cat . You must clearly indicate in your request which rights you exercise. Additional information: if you wish to expand this information you can consult the salutweb.gencat.cat/ca/ the_department/data-protection.

The camps marked with a * are mandatory