Model Consent Form

CONSENT FOR THE COLLECTION AND PROCESSING OF PERSONAL DATA FROM THE EUROPEAN UNION

Note: This is a model consent form only and will need to be revised for your business purpose. Please contact your campus/institute data protection officer or the office of general counsel prior to distributing consent form to data subjects.

    1. Pursuant to the European Union General Data Protection Regulation (“EU GDPR”), The University of Tennessee (“UT”), in its capacity as a data controller and/or processor under the EU GDPR, must obtain your explicit, affirmative, and informed consent before it can collect or process any personal data for a lawful basis, including, but not limited to, employment, admission and enrollment, study abroad, internship abroad, online education, etc. For information on how UT uses personal data, please review the [Privacy Notice] [insert link].
    2. “Personal data” means any information relating to an identified or identifiable natural person (a “data subject”). An identifiable natural person is one who can be identified, directly or indirectly, in particular by reference to an identifier such as a name, an identification number, location data, an online identifier or to one or more factors specific to the physical, physiological, genetic, mental, economic, cultural, or social identity of that natural person.
    3. Any personal data that is collected from you will be for the sole purpose of [choose the correct purpose from bullet list and delete the others]
      • application for admission to UT that is sent from the EU
      • planning and organization of study abroad program in the EU, and performance of academic services in connection therewith, at ___________ institution
      • planning and organization of, and enrollment and participation from an EU location in, a distance learning study program at UT
      • an employment relationship with UT taking place in the EU at _______________ institution
      • application for an employment relationship with UT that is sent from the EU
      • participation in a research study (specify research study title)
      • OTHER: _____________________________________ (please specify)

       
      and is necessary for that purpose. This may include processing the personal data as required to execute contractual obligations in connection with the previously described purpose and compliance with applicable laws, to execute the obligations to you concerning your [choose the correct item from bullet list and delete the others]

      • enrollment as a student at UT.
      • enrollment in a study abroad program, including course attendance and other academic requirements, dietary requirements and health and safety information.
      • enrollment and/or participation from an EU location in a distance learning study program at UT, including course attendance and other academic requirements.
      • employment in the EU, including including payroll management, salary payments, tax compliance and health and safety information.
      • employment at UT, including including payroll management, salary payments, tax implications and health information.
      • participation in a research study (specify research study title).
      • OTHER: _____________________________________ (please specify)

     

    Personal data regarding a legal process which may have been provided to UT by public authorities will be processed only for the purposes relating to a health or safety emergency and complying with any applicable law.

    1. Notwithstanding anything to the contrary herein, UT may process personal data without the data subject’s consent under certain other lawful bases, including when processing is necessary for the performance of a contract to which a data subject is a party; when processing is necessary for compliance with a legal obligation to which UT is subject; or when processing is necessary to protect vital interests, such as the life of a data subject.
    2. Personal data will be handled and processed only by the persons who are responsible for the necessary activities for the purpose above, and may be transmitted from the EU to one of UT’s campuses or institutes in Tennessee.
    3. Refusal of consent may make it impossible for UT to carry out its necessary activities for the purpose above, and may preclude UT’s ability to provide requested [educational services] [employment] [participation in a research study] [other] to you.
    4. You have the right to withdraw your consent to the collection and processing of personal data. If you would like to withdraw consent, please contact the Data Protection Officer for your campus or institute at privacy@tennessee.edu.
    5. UT is committed to ensuring the security of your information. We have put in place reasonable physical, technical, and administrative safeguards designed to prevent unauthorized access to your information.

     
    Having read this notice, __________________________________________________[Print Full Name Here], the undersigned, hereby:

       gives consent      does not give consent

    for the use of his/her personal data, and the transfer of personal data overseas, for the purpose outlined in this notice.

    Date [Month/Day/Year]: ____________________________
    Signature _________________________________________
     

    [[ADD THE FOLLOWING LANGUAGE FOR EU STUDY ABROAD PROGRAMS/INTERNSHIPS/OTHER EU-BASED ACTIVITIES]]

    I also hereby waive my right to privacy of confidentiality regarding ________________________ (EU Institution hosting student/employee) reporting to the appropriate authorities at UT if I am seriously ill, suffer an injury, am the victim or perpetrator of harassment, whether on or off campus, am the victim of the perpetrator of sexual or gender-based misconduct and/or of criminal behavior, whether on or off

    campus, and I grant the authorities of ________________________ (EU Institution hosting student/employee) staff, faculty and administrators full authority to report to the appropriate UT authorities any and all such incidents, under the applicable laws (including but not limited to Title IX and the Clery Act), whether or not it involves disciplinary action.
     
    Date [Month/Day/Year]: ____________________________

    Printed Name ______________________________________

    Signature _________________________________________
    Signatures can be in handwritten or digital format.
     
    If you have questions about this Consent, please contact the Data Protection Officer for your campus or institute at privacy@tennessee.edu:

    • UT Knoxville: Joel Reeves, Associate Vice Chancellor and CIO
    • UT Chattanooga: Dr. Richard Brown, Executive Vice Chancellor for Administration and Finance
    • UT Martin: Edie Gibson, Executive Assistance to the Chancellor
    • UT Health Science Center: Melanie Burlison, Assistant Vice Chancellor for Compliance and Special Projects
    • UT Institute of Agriculture: Sandy Lindsey, Chief Information Security Officer
    • UT Institute for Public Service: Scott Gordy, Chief Information Security Officer
    • UT Foundation: Michael Carter, Assistant Vice President of Advancement Services
    • UT System Administration: Robert Ridenour, Chief Information Security Officer

    Revised May 22, 2018

    An editable Word document version of the Consent for the Collection and Processing of Personal Data from The European Union.