Privacy Act Complaint Form

Question 1 – Have you already contacted the agency about your complaint?
In most cases where a breach of the Privacy Act is alleged, it is appropriate for you to first contact the agency responsible for the information and allow it an opportunity to explain or fix the issue(s) for you. We might decline to investigate your issue(s) until you have made contact with the responsible agency.

Please circle Yes or No, and follow the instructions accordingly.
Yes / I have contacted the agency concerned to try and resolve the issue(s) but I have been unsuccessful. I attach all of my correspondence with the agency.
No / I have not contacted the agency concerned. My reasons for not contacting the agency are as follows:
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Question 2 – Your details
Complainant’s Details
Title / ______
First Name / ______
Surname / ______
Representative’s Details (if applicable)
If you are using a representative like an advocate or a lawyer, tell us who they are. (If you are completing this form as someone’s representative, tell us who you are.) If your representative is not a lawyer, please complete our Representative Authority Form (copy attached) and return it to us.
Title / ______
First Name / ______
Surname / ______
Contact Details
We need to be able to contact you about your complaint. Tell us how we can contact you or if you are using a representative, how we can contact them. (If you are completing this form as someone’s representative, tell us how to contact you.)
Postal Address / ______
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Email / ______
Telephone No.(s) / ______
Question 3 – Which agency are you complaining about?
Name / ______
Postal Address / ______
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Telephone No.(s) / ______
Your relationship to the agency (e.g. employee or client):
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Question 4 – What’s your complaint about?
Please describe how you think your privacy has been interfered with.
It will assist us if you can explain, as clearly as possible:
  • What happened?
  • When did it happen?
  • What personal information about you was affected?
  • Who did it?
  • How and when did you find out about it?

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Question 5 – How have you been affected?
It is important that we understand how the agency’s actions have affected you. The law requires us to take this into account in assessing if there has been an interference with your privacy.
The ways you may have been affected can be, for example, physical, financial or emotional. If the effect on you has been emotional, this would usually have to be significant – that is, more than ordinary or trivial.
Please tell us how the agency’s actions have affected you, and provide evidence if you have any.
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Question 6 – What would resolve this complaint for you?
We try to resolve complaints, so please tell us what action you want the agency to take to resolve your complaint.
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Unless you have serious objections, we might meet with you and the agency to try and resolve your complaint. If appropriate, are you willing to have such a meeting take place?
Yes/No (please circle one)
Completed by / ______
Date / ______
Signature / ______

Send your completed form(s)to the

Office of the Privacy Commissioner, PO Box 10094, Wellington 6143,

fax it to us at 04 474 7595, or email it to .

We will send you a formal acknowledgement within 3 working days

that we have received your complaint.

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Complaint about alleged breach of privacy

Representative authority form

This authority to act is for my Privacy Act complaint about the following agency:

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I, ______, give permission and authorisation for the following person to act on my behalf and have access to any information concerning me in respect of my complaint:

My representative’s details
Title / : / ______
First Name / : / ______
Surname / : / ______
Postal address / : / ______
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Email / : / ______
Telephone number(s) / : / ______
Signed (by complainant) / : / ______
Date / : / ______

Please complete this authorisation, sign, date and

upload it with your complaint if you are lodging it online or return it to the

Office of the Privacy Commissioner, PO Box 10 094, Wellington 6143

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