Details of the person this request is about (the 'Subject').

Name(Required)

First Last

Phone(Required)

Email(Required)

How would you like us to contact you?

Date of birth (dd/mm/yyyy)(Required)

NHS number (if applicable)

National insurance number (if known)

Address(Required)

Street Address Address Line 2 City Postcode

If you/the subject has been known by a different name or has lived at a different address during the time span of your enquiry, please give details below:

Who is this request for?

I am requesting information about myself

I am requesting information on behalf of someone else

Written authority to act on behalf of the person you are making the request for

If you are not the subject, but are acting on behalf of the subject, please tell us details below. We need to know what gives you the authority to act on their behalf, so please state your relationship with them. For example, parents, solicitor or holder of power of attorney.

Name(Required)

First Last

What is your relationship with the data subject?(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City Postcode

Proof of identity

We may need to verify your identity in order to supply your information to you. If you are applying on behalf of someone else, we will need to see proof you have authority to access these records.

Are you able to provide proof of identification/authority?(Required)

Yes

Helping us to find the information

Please use the space below to provide details that may help to locate your information. Being clear about the information you require will help us to respond promptly to your request. If you think you require further information, you can always submit a further request and there are no fees attached to your right of access. Please supply as much detail as possible.

What information would you like to be provided?(Required)

Is there a date range you are interested in?(Required)

Where would you like copies of your information sent?

Our preferred method of delivery is via email. Any documents sent will be password protected and sent securely. If you would like to receive your information by post, please note that information posted by special delivery will need a signature upon receipt. However if the Royal Mail are unable to deliver to the address given and need to return the documentation to Hafod this will be returned by normal post (that is, not securely)

Your preferred method of delivery(Required)

Home address

Over the phone (this is only available in specific circumstances

Declaration

Knowingly or recklessly obtaining or disclosing personal data is an offence under data protection legislation. By signing this form, you are giving agreement that your personal data (or that of the person you are acting in behalf of) can be shared within Hafod in order that we may process your request and provide you with the information sought. Your personal data will be kept in accordance with Hafod Retention and Destruction procedures.

Signature (please print your name)(Required)

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Subject access request form