Online Survey - Page 1

The questions marked with an asterisk (*) must be answered.

Commune

Civilité

Madame

Monsieur

Nom de naissance

Nom d'usage

Prénom

Sexe

Homme

Femme

Autre

Téléphone

Email

Si cette demande vient d'un partenaire, merci de nous préciser :

Autorisations

Plusieurs réponses possibles

Je déclare ne pas avoir de médecin traitant

Je donne mon consentement pour que les informations que j'ai renseigné servent à la création et à l'alimentation d'un dossier patient sur la plateforme MonSisra. Ces données pourront être partagées aux professionnels qui participent à ma prise en charge dans le respect de ma vie privée et du secret professionnel. Le traitement des données est conforme au Règlement Général de Protection des Données (RGPD).

I agree to the processing of my personal data by CPTS du Brivadois. Learn more

The following survey questionnaire is designed and distributed by CPTS du Brivadois

PURPOSE OF DATA PROCESSING

Objectives

The data processing is aimed at d'étudier les conditions d'exercice des professionnels.

PROCESSED DATA

Type of processes carried out

Collection, recording, organization, preservation, adaptation, modification, extraction, consultation, use, communication by transmission, dissemination or any other form of provision, alignment or interconnection, locking, erasure or destruction.

Categories of processed data

Données d'identification

Data Source

These informations are directly collected from the person answering the questionnaire.

INDIVIDUALS CONCERNED

Data processing concerns natural and legal persons answering the questionnaire.

DATA RECIPIENTS

Categories of recipients

Salariées de la CPTS du Brivadois

DATA RETENTION PERIOD

18 months

SECURITY

We continuously protect your information.

For this, we implement all necessary technical and organizational security measures to protect your data, against any unauthorized access, modification, loss, disclosure, alteration, or destruction.

YOUR RIGHTS OVER YOUR DATA

The applicable regulation on data protection gives you specific rights that you can exercise, at any time and free of charge, to control the use we make of your data.

Right to access and copy your personal data as long as this request does not contradict trade secrets, confidentiality, or correspondence secrecy.
Right to rectification of personal data that would be incorrect, outdated or incomplete.
Right to request erasure ("right to be forgotten") of your personal data which would not be essential for the proper functioning of our services.
Right to limit your personal data that allows to photograph the use of your data in case of dispute on the legitimacy of a treatment.
Right to portability of your data which allows you to retrieve part of your personal data in order to store or transmit them easily from one information system to another.
Right to give directives on the fate of your data in case of death through you, a trusted third party, or a rights holder.

For a request to be considered, it is imperative that it is made directly by you at the following address contact@cpts-du-brivadois.fr. Any request that is not made in this way cannot be processed.

Requests cannot come from anyone other than you. Therefore, we may ask you for proof of identity if there is any doubt about the identity of the requester.

We will respond to your request as soon as possible, within three months of receiving it, in case the request is technically complex or if we receive many requests at the same time.

Please note that we can always refuse to respond to any excessive or unfounded request, particularly with regard to its repetitive nature.

Exercising your rights

The data protection officer is your contact for any request to exercise your rights on this treatment.

Contact the officer by electronic means: contact@cpts-du-brivadois.fr

Complaint (grievance) to the CNIL

You can contact the French supervisory authority for data protection (the "National Commission for Information Technology and Liberties" or "CNIL") at any time at the following address: Complaints service of the CNIL, 3 Place de Fontenoy - TSA 80751, 75334 Paris Cedex 07 or by phone at 01.53.73.22.22.

DATA TRANSFER OUTSIDE OF THE EUROPEAN UNION

No data transfer outside the EU

AUTOMATED DECISION MAKING

Non-automated decision making