Subject Access Request Form /
Personal Details(please print clearly in pen)
Surname: / Date of Birth:
First Names:
Address:
Post Code:
Phone (day): / (eve):
Request Details
The Council uses personal data for the purposes shown below.If you would like to access personal data held about you for all of these
please tick this box.
If you would like to access personal data for only some of these
purposes please tick the box opposite the purpose(s) you wish to access
Housing Benefit / Rent Collection / Council Tax
Building Control / Planning / Housing
Licensing / Social Services / Education
Personnel (recruitment) / Library & Leisure Services / Other
Environmental Health & Consumer Protection
Additional Information(in support of the above – if necessary)
Data Subject Declaration
I request that you provide me with a copy of my personal data that you process for the purposesI have indicated above.
I confirm that I am the Data Subject and not someone acting on their behalf.
Signed: / Date:
Agent Authority(this section to be completed by person(s) acting on behalf of the data subject)
I confirm that I am acting on behalf of the Data Subject and attach letter of authorisation
Signed: / Date:
Phone (day): / (eve):
This form should be returned in person to any Council Office or by post to Records & Information Compliance Team, Stirling Council, Viewforth, Stirling, FK8 2ET
January 2011
Stirling Council Use Only
Stage 1 – Records & Information Compliance (check form)
Date received: / Checked by:Date acknowleged: / Date passed to DPR:
15th Day: / 30th Day: / 40th Day:
Stage 2 – Data Protection Representative(information assembly/checking)
Date received: / 40th Day:
Notes:
Stage 3 – Data Protection Representative(invite subject (agent) to viewing or post recorded delivery )
Date response sent: / Response time / Days
Stage 4 – Date Protection Representative (information viewing)
Identity Check – Data Subject(Agent) must produce one of the following before they are allowed
access to the information. Accept only originals
Birth Certificate: / Passport: / Driving Licence:
Other:
Agent: letter of authorisation:
Checked by:
A member of staff must be present at the viewing
Notes:
Date information copied to Data Subject (Agent):
Appeal – Data Protection Representative
Date received: / 15th Day: / Date response sent
* working days
Action taken:
January 2011