Fillable Subject Access Request (Staffordshire County Council)

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Subject Access Request (Staffordshire County Council)

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Page 1
of 6
CONFIDENTIAL
Subject Access Request
Please complete this form if you are requesting your own social care information from when
you were a child or if you are requesting children’s social care information on behalf of
someone else such as your child or legal client.
If you have any questions in relation to making a Subject Access Request or if you require any
help completing this form then please contact the Access to Personal Information Team by
calling 01785 278090 or email informationrequests@staffordshire.gov.uk
If you require a copy of this form in large print, Braille, another language or in another format
then please let us know.
1
I am applying for
My own information
Go to section -3-
My child’s information
Go to section -2-
Information on behalf of someone else
2
Applying for someone else’s information
If you are applying for someone else’s information then provide us with your details below:
Title: First Name(s):
Surname:
Address:
Tel Number: Email:
Your relationship to the data subject:
If you are requesting another person’s information (including a child’s) then please note that
there is not an automatic right of access and your request may be refused. We reserve the
right to contact the person whose information you are requesting to seek their consent for
you to act on their behalf and access their information. This can depend on the age and
competency of the person.
Please now complete section -3-
Page 2
of 6
3
The Data Subject(s) – Whose information is being requested
Subject 1
Title: First Name(s):
Surname:
Previous name(s):
Address:
Tel Number: Email:
Date of Birth: D D / M M / Y Y Y Y
Subject 2
Title: First Name(s):
Surname:
Previous name(s):
Address:
Tel Number: Email:
Date of Birth: D D / M M / Y Y Y Y
Subject 3
Title: First Name(s):
Surname:
Previous name(s):
Address:
Tel Number: Email:
Date of Birth: D D / M M / Y Y Y Y
Subject 4
Title: First Name(s):
Surname:
Previous name(s):
Address:
Tel Number: Email:
Date of Birth: D D / M M / Y Y Y Y
If you wi
sh to include more individuals then please provide the same details on a separate sheet.
Please now complete sections -4- & -5-
Page 3
of 6
4
Involvement with Staffordshire County Council
Please provide us with details about when you or the data subject(s) w
ere in contact with Staffordshire
County Council. Please include the dates you were in contact, the department(s) you were in contact with
as well as the names of any staff members or reference numbers you may have been given:
5
The information you are requesting
Please describe what information you are requesting below. Please be as specific as possible as this will
help speed up your
request. For instance, you may request information between specific dates, or specific
documents. Please note that if you are requesting all information held then this may take longer for us to
provide depending on how much information we hold.
Please now complete section -6-
Page 4
of 6
6
Declaration
The information I have supplied in this application is correct to the best of my knowledge. I am the person
to whom this request relates or I am representative acting on their behalf. I understand that it is a criminal
offense to knowingly obtain, disclose or procure the disclosure of information that I have no legal right to.
Signed by the data subject:
Signed by agent/third party (if applicable):
Date: D D / M M / Y Y Y Y
The information provided on this form will be processed by Staffordshire County Council in
accordance with the General Data Protection Regulation (GDPR). The data you provide will
be used by the County Council solely to process your Subject Access Request. For further
information on our privacy policy and how we use your data, please visit our website:
www.staffordshire.gov.uk
Please now complete section -7-
Page 5
of 6
7
Proof of Identification
Under the Data Protection Act 2018 we require evidence of your identity, and if you are
requesting information on behalf of someone else, we also require evidence that you have the
right, or are authorised to do so. Please provide copies (not originals) of documents listed
below:
Please provide one item from List A and one from list B:
LIST A- LIST -B-
Passport Utility bill
Photocard Driving Licence Bank or building society statement
Foreign National Identity Card Council tax bill/statement
Birth Certificate Mortgage statement
Biometric residence permit Credit card statement
Marriage/civil partnership certificate P45 or P60 statement
Adoption certificate Benefit/pension statement
If you are a parent requesting information relating to your child(ren) (under the age of 12) then in
addition to lists A & B, please include proof of parental responsibility by providing one item from List C:
LIST -C-
Child’s full birth/adoption certificate naming you as the mother/father
Parental responsibility agreement between birth parents
Court order granting you parental responsibility
If you are a solicitor requesting information on behalf of your client then please provide proof that you
have authority to act on their behalf:
Written confirmation of instruction from the data subject (or parent for a child under 12)
If
you are requesting information on behalf of someone else, then please provide us with copies of their
identification documents (one from list A and one from list B above) as well as written confirmation that
they give you the authority to act on their behalf.
Data subject’s identification (List A and B) and written confirmation of authority to act on
their
behalf.
Please go to section -8-
Page 6
of 6
9
What to do next
Please send this form along with the relevant identification documents stated in section 7 to the following
email address: informationrequests@staffordshire.gov.uk
Or you can post this form and copies of the relevant identification documents to the following address:
Access to Personal Information Team
Staffordshire County Council
Staffordshire Place 1
Tipping Street
Stafford
ST16 2DH
Once we have received your request we will use the information provided by you to search our files and
systems for the information requested. This will normally take up to one calendar month however, this
can be extended by 2 months if your request is complex. We will let you know if this extension is to be
applied to your request.
We will also contact you if any of the following apply:
We require further information from you in order to process your request
We do not hold the information you have requested
The information you have requested is held but an exemption to supplying it is to be considered
If none of the above apply to your request, then we will contact you once the information is ready to be
released. For security we normally release information by email. You will receive a link to our secure file
transfer website where you will be able to download the records to any computer or mobile device with
internet connectivity.
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Subject Access Request (Staffordshire County Council)

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Completed 6 December 2020

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