ࡱ> psoc bjbj fff   aa---8e\D-o?&pu:(((>>>>>>>$AKD ?+'0("++?aa )?"0"0"0+ja<>"0+>"0"02;=ލՐK+<.>??0?(=·,·=·=<(hS)J"0)<)5(((??V.(((o?++++WE((((((((( ':    SHAPE \* MERGEFORMAT    SHAPE \* MERGEFORMAT  If you are acting on behalf of the data subject you will need to enclose their written authority including a signature or other legal documentation (e.g. parental rights or power of attorney).  SHAPE \* MERGEFORMAT   SHAPE \* MERGEFORMAT    SHAPE \* MERGEFORMAT   Your Checklist: Have you completed all of the appropriate sections? Have you signed the form? Have you enclosed evidence of the data subjects identity? If acting on behalf of the data subject, have you enclosed evidence of your and their identity? Evidence (written consent) from the data subject to act on their behalf? 鶹Ƶ Corporate Information Governance Team PO Box 16366 鶹Ƶ B2 2YY Email:  HYPERLINK "mailto:infogovernance@birmingham.gov.uk" infogovernance@birmingham.gov.uk The details you provide on this form will be disclosed to officers dealing with your request and will be used within 鶹Ƶ to validate, locate and review your information. The Corporate Information Governance Team will retain your request for a period of 3 years from receipt of your request.      SHAPE \* MERGEFORMAT  PAGE 6 PAGE 3/4 BCC Subject Access Request form Social Care Version 1 鶹Ƶ Data Protection Act 2018 Right of Access to Personal Data Adults Social Care Subject Access Request Form 1. Details of the person about whom the council is holding data (the Data Subject) Full Name: ____________________________________________ Other Names by which you may have been known: ________________________________________________ Date of Birth: ___________________________ Current Address: __________________________________________ __________________________________________ Post Code: _______________ Tel No: ______________________ Email _________________ Mobile ______________________ 2. Have you lived at a different address in the last 2 years? If you have, please give the address you have lived at previously. If you have not, please go to section 3. Previous Address 1 Previous Address 2 ________________________ _________________________ ________________________ _________________________ ________________________ _________________________ 3. Are you the person named in 1 above? Yes No If Yes, please provide evidence of your identity: Copy of Driving Licence Copy of Passport Birth Certificate Council Tax Bill Utility Bill (recent) For anyone currently serving a prison sentence then prison headed paper, prison number and signed by a prison officer Go to section 5. If No Please complete section 4 next 4. If you are not the person about whom the council is holding the data, please give your: Full Name : ____________________________________________ Current Address : _______________________________________ _______________________________________ Post Code : _________________________ Tel No : ____________________________ Email: _____________________ What is your relationship to the data subject : ___________________________ You wi You will also need to enclose evidence of your identity and that of the Data Subject. 5. Please tick the box below to indicate which type of information you are requesting: Adult Social Care To enable us to locate the information you are requesting, please describe in detail the information you are seeking below together with any relevant information such as Care Team, Service Area, Care Home etc. 6. To be completed by all applicants: I, __________________________, certify that the information given on this subject access request form is true. Print Name:________________________________ Signature: ________________________________ Date: ________________ Note the Council must respond to your request within 30 days. However, this period does not start until the council is satisfied about your identity, and has enough detail to locate the information you are seeking. Please note that any attempt to obtain personal data unlawfully may lead to prosecution. If you are not the data subject or acting on behalf of the data subject (with their written consent) but are attempting to gain access to information that you are not entitled, you will be in breach of DPA and could lead to Enforcement Action being taken by the Information Commissioners Office. 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