Making a request under the Data Protection Act

Name *

Email *

Address *

Postcode *

Contact number *

I am requesting for...

A public body (police, HMRC, CQC, H&S executive)

A utility company

On behalf of someone (local authority, solicitor, relative, healthcare professional, social worker, carer)

Information about myself

Requests from public bodies

Under Schedule 2 of the Data Protection Act 2018 please use this form where access to personal data is required for the following purposes *

The prevention or detection of crime

The apprehension or prosecution of offenders

The assessment or collection of tax or similar

1. I require access to the following personal information (for CCTV please include date, time and location. Please note requests may take up to 14 days):

2. This information relates to the following subject

Name *

DOB *

Midland Heart address *

3. Reason for your enquiry *

By completing this form

I confirm that the personal data requested below is needed for the purposes indicated above and a failure to provide that information will be likely to prejudice those matters. *

I confirm that the individuals whose personal data is sought should not be informed of this request as to do so would be likely to prejudice the matters described above. *

I confirm that the personal information provided to me by Midland Heart will only be used for the purpose specified on this form and will not be passed to other third parties without express written permission being obtained from Midland Heart first. *

Name *

Designation *

Senior official, name and designation (police only)

For and on behalf of

Request from utility company

Your Company *

Utility your company provides *

Address your enquiry is about *

Information you are seeking *

Your previous address(es) if moved in last 3 years *

DOB *

Are you a customer or employee? *

Customer

Employee

These are examples, there may be personal data that lawfully cannot be disclosed to you. Information provided to us from third parties may not be disclosed to you.

Your own complaint data - Your own ASB/Case file data - Supported/Retirement Living notes - Money Advice information - Income team notes - Customer Services notes - Housing team notes - Lettings notes - Telephone recordings - Emails about you - Health data relating to your aids/adaptations works

These are examples, there may be personal data that lawfully cannot be disclosed to you. Information provided to us from third parties may not be disclosed to you.

HR File: (includes: disciplinary, capability, absence management, sickness certificates, occupational health notes, contract) - Emails: about yourself - Instant Messages: messages about yourself (you must provide all relevant email addresses including your own. We are unable to provide mobile phone messages)

I am requesting access to the following personal data *

Date range for personal data being requested *

Relevant telephone numbers/email addresses

I hereby confirm the above information is correct *

Consent for storing submitted data *

Yes, I give permission to store and process my data