| This form is for any person who wishes to apply for access to personal data held by [Organisation Name]. Please read the Subject Access Request Guidance Notes below before completing this form. A separate form should be completed for each individual. |
| NOTE: This is not a mandatory form Subject Access requests made in other formats will also be accepted but this form is designed to speed up the process. |
Subject Access Request Guidance
Please read before filling in the Subject Access Request Form
Which sections should I complete?
Sections 1, 2, 3, 4 and 5 should be completed for all applications.
Sections 6, 7 and 8 (Representative Details and Authority to Release Information to a Representative) should only be completed if the application is being made by a representative (i.e. someone other than the data subject themselves).
Section 3 (Proof of the applicants identity) - If you do not have any of the forms of identity listed, we may in exceptional circumstances accept alternatives for consideration.
This form is designed to assist the process of making a subject access request and, as a consequence, may speed the process up but it is not mandatory, all subject access requests made in other formats will also be processed.
What information will help with the processing of my subject access request?
Identification of relevant records will be easier if you can provide any references issued by [Organisation Name]relating to applications you may have made or action taken against you.
If you cannot provide us with satisfactory proof of identity, your application will be rejected.
What information does [Organisation Name] hold?
[Organisation Name]holds information relevant to the conduct of its functions which will include, but not be restricted to, personal information about applications you have made and any services you have used. However, some data may have been reviewed and destroyed where appropriate in accordance with our information retention policies.
[Organisation Name]is also the data controller for certain information held by other bodies which are contracted by [Organisation Name]in connection with the conduct of specific activities.
How long will it take to get my data?
Once we are satisfied that you meet the criteria for disclosure of data under the Data Protection Legislation, and have provided sufficient information, you should receive a response within 4 weeks from the date that we accept your application for processing.
Records may be held in several different locations in paper and electronic formats. If you only require specific information and you clearly state what that is for example a specific document or IT-only data then you are likely to get a quicker disclosure.
The form includes a section for giving details if you need a disclosure by a certain date. No guarantee can be given that a disclosure will be completed by that date but we will endeavour to comply with reasonable requests for expedited action.
GENERAL NOTES
We will acknowledge your application in writing and we will provide you with a reference number when we write to you.
When we process information requests for children aged 13 or over and spouses, we require their signature of authority before disclosing data. A separate application form should be completed for each individual. Sections, 4 and 5 should be completed by a parent/guardian for a child under 13.
The documents that you receive may have data redacted (blacked-out) or contain rough notes that may lack clarity. This is because we aim to supply copies of the original records whenever possible. However, as [Organisation Name] records also include third party information that we cannot release to you under the Data Protection Act, e.g. another persons data, this is removed.
We will not disclose information by fax or telephone. Disclosure by post is usually made by secure courier post to the address you provide in section 2 or, if appropriate, to your representative named in section 6.
CHECKLIST
| Have you completed all relevant sections of the form? | |
| If you are a representative, has your client signed the authority in Section 8 or provided a separate signed note of authority? | |
| If you are submitting the form yourself, have you signed the form at Section5? | |
| If you are signing as a parent or guardian of a child under 13, have you provided a photocopy of their full birth certificate, photocopies of any court orders and proof of your parental responsibility? | |
| Have you enclosed two pieces of identification from the lists in Section 3 (one from each of A and B)? | |
| Have you signed the declaration in Section 5? | |
| Have you provided as much information as possible to enable us to find the data you require? |
Please send your completed form, proof of identity and fee to:
The Data Protection Officer
Address
Address
Address
PLEASE NOTE that [Organisation Name]only holds information relevant to [Organisation Name] services. For more details please refer to [Organisation Name] Privacy Notice or any specific contract between you and [Organisation Name](where relevant)
SECTION 1 APPLICANT DETAILS
| Title (please tick one): | Mr [ ] Mr [ ] Miss [ ] Ms [ ] Title (please state): |
| Forename(s): | |
| Family Name: | |
| Previous Family Name: | |
| Other name(s) known by: | |
| Date of Birth (dd/mm/yyyy): | .././. Male [ ] or Female [ ] |
| Nationality: | |
| Place of Birth: | |
| [Organisation Name]Reference Number: | Reference: .. |
SECTION 2 APPLICANT DETAILS
| Current Address: | |
| Postcode | |
| Daytime Telephone No: | |
| Email Address: | |
| Previous Address: | |
| Postcode: |
SECTION 3 PROOF OF THE APPLICANTS IDENTITY
| List A (photocopy of one from below) | List B (plus one original from below) | ||
| Passport/Travel Document | A letter sent to you by the Passport Office | ||
| Photo driving licence | Utility bill showing current home address | ||
| Foreign National Identity Card | Bank statement or Building Society Book | ||
| Child under 13 : Full birth certificate | |||
| Child under 13 : Court Order(s) |
For a child under 13 years of age please provide photocopies of all Court/Legal Orders. Please state if there are none
Any original documents you send to us will be returned by secure courier.
SECTION 4 DETAILS OF INFORMATION REQUIRED
Please use this space to give us any details about the information you are requesting, for example by stating specific documents you require (use extra sheets if necessary):
Please note in the case of CCTV images [Organisation Name] are only able to retrieve images that are less than [??] days old.
SECTION 5 DECLARATION
The information which I have supplied in this application is correct, and I am the person to whom it relates or a representative acting on his/her behalf. I understand that the [Organisation Name]may need to obtain further information from me/my representative in order to comply with this request.
| Signature of Applicant: | Date: |
SECTION 6 REPRESENTATIVE DETAILS
(If completed [Organisation Name]will reply to the address you provide in this section)
| Name of Representative: | |
| Company Name: | |
| Address & Postcode: | |
| Daytime Telephone No: | |
| Email Address: |
SECTION 7 PROOF OF THE REPRESENTATIVES IDENTITY
| Please provide copies of two pieces of identification, one from list A and one from list B below and indicate which ones you are supplying. Please DO NOT send an original passport, driving licence or identity card |
| List A (photocopy of one from below) | List B (plus one original from below) | ||
| Passport/Travel Document | A letter sent to you by the Passport Office | ||
| Photo driving licence | Utility bill showing current home address | ||
| Foreign National Identity Card | Bank statement or Building Society Book |
SECTION 8 AUTHORITY TO RELEASE INFORMATION TO A REPRESENTATIVE
A representative needs to obtain authority from the applicant before personal data can be released. The representative should obtain the applicants signature below, or provide a separate note of authority.
This must be an original signature, not a photocopy (tip: using blue ink often helps verification).
If the applicant is signing as the guardian of a child under 13, proof of legal guardianship must also be provided.
| I hereby give my authority for the representative named in Section 3 of this form to make a Subject Access Request on my behalf under the Data Protection Legislation. |
| Signature of Applicant: | Date: |
| Signature of Representative: | Date: |
SECTION 9 TIMESCALE
If you have specific reasons for requiring data by a specific date please give details below:
| (a) Date required: |
| (b) Reason (please state and supply supporting evidence): |
