Subject Access Request Form | Healthwatch Hertfordshire

If you would like us to supply you with a copy of any personal data we hold about you, please complete this form. You are entitled to receive this information under the General Data Protection Regulation (GDPR).

We will also provide you with information about any processing of your personal data that is being carried out, the retention periods which apply to your personal data, and any rights to rectification, erasure, or restriction of processing that may exist.

The information you supply in this form will only be used for the purposes of identifying the personal data you are requesting and responding to your request.

First

Middle

Last

Please enter your full name.

Address

Address 2

City/Town

Postcode

Please enter your home address, including your postcode.

Phone number

Please enter your telephone number.

Email address

Please enter your email address.

Are you the data subject?

Yes. I am the data subject. I attach proof of my identity and address (see below).

No. I am acting on behalf of the data subject. I have attached the data subject's written authority and proof of the data subject's identity and address, and my own identity and address (see below).

Please select your answer from the options provided. If we are not satisfied you are who you claim to be, we reserve the right to refuse to grant your request.

Proof of identity

We need a digital copy of one of the following: passport, photo driving license, national identity card, birth certificate.
One file only.
40 MB limit.
Allowed types:

gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

Proof of address

We need a digital copy of one of the following: utility bill, bank statement, credit card statement (no more than 3 months old); current driving license, local authority tax bill.
One file only.
40 MB limit.
Allowed types:

gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

Proof of your identity

We need a digital copy of one of the following: passport, photo driving license, national identity card, birth certificate.
One file only.
40 MB limit.
Allowed types:

gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

Proof of the data subject's identity

We need a digital copy of one of the following: passport, photo driving license, national identity card, birth certificate.
One file only.
40 MB limit.
Allowed types:

gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

Proof of your address

gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

Proof of the data subject's address

gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

Written authority from the data subject

Please provide written evidence that the data subject is aware you are acting on their behalf, and have given permission for you to do so.
One file only.
40 MB limit.
Allowed types:

gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

First

Middle

Last

If you are completing this form on behalf of somebody else, please enter the full name of the person you are acting for (the data subject).

Address

Address 2

City/Town

Postcode

Please enter the data subject's home address, including the postcode.

Data Subject's Phone Number

Please enter the data subject's telephone number.

Data Subject's Email Address

Please enter the data subject's email address.

What information are you seeking?

Please describe the information you are seeking. Please provide any relevant details you think will help us to identify the information you require. Please note that if the information you request reveals details directly or indirectly about another person we will have to seek the consent of that person before we can let you see that information. In certain circumstances, where disclosure would adversely affect the rights and freedoms of others, we may not be able to disclose the information to you, in which case you will be informed promptly and given full reasons for that decision. While in most cases we will be happy to provide you with copies of the information you request, we nevertheless reserve the right, in accordance with Article 12 of the GDPR to charge a fee or refuse the request if it is considered to be “manifestly unfounded or excessive”. However, we will make every effort to provide you with a satisfactory form of access or summary of information if suitable.

Information about the data collecting and processing

Why we are processing your/the data subject's personal data

To whom your/the data subject's personal data is disclosed

The source of your/the data subject's personal data

Please select from the options provided the information you would like us to compile from our records about you/the data subject. Please tick all that apply.

Disclosure of video and photo images - If the information you seek is in the form of video and/or photo images, would you be satisfied with viewing these images?

Please answer yes or no, as needed.

Additional comments

Please enter here any additional comments you have.

Declaration

I confirm that I have read and understood the terms of this Data Subject Access Request Form and certify that the information given in this application to Healthwatch Hertfordshire is true. I understand that it is necessary for Healthwatch Hertfordshire to confirm my / the data subject’s identity and it may be necessary to obtain more detailed information in order to locate the correct personal data.