Privacy complaint - Internal review application form

 

Click here to download the WORD version of this form

 

This is an application for review of conduct under: (please select one)

Note: It is not a requirement under the PPIP Act or the HRIP Act that you complete an application form. This form is designed for your convenience only. However, you must make a written request in some form to the agency for the matter to be a valid internal review.

1. Name and address of the agency you are complaining about:

Note: The PPIP Act regulates NSW state government departments, area health services, most other state government bodies, and NSW local councils. Each of these is defined as a "public sector agency". The HRIP Act regulates private and public sector agencies and private sector persons.

__________________________________________________

__________________________________________________

2. Your full name

__________________________________________________

3. Your contact details

Postal address

__________________________________________________

__________________________________________________

Telephone number

__________________________________________________

Email address

__________________________________________________

4. If the complaint is on belhalf of someone else, please provide their details:

__________________________________________________

What is your relationship to this person (e.g. parent)?

__________________________________________________

Is the person capable of making the complaint by himself or herself?

Yes

No

Unsure

5. What is the specific conduct you are complaining about?

Note: "Conduct" can include an action, a decision, or even inaction by the agency. For example, the conduct in your case might be a decision to refuse you access to your personal information, or the action of disclosing your personal information to another person, or the inaction of a failure to protect your personal information from being inappropriately accessed by someone else.

__________________________________________________

__________________________________________________

6. Please tick which of the following describes your complaint: (you may tick more than one option)

  • collection of my personal or health information
  • security or storage of my personal or health information
  • refusal to let me access or find out about my own personal or health information
  • accuracy of my personal or health information
  • use of my personal or health information
  • disclosure of me personal or health information
  • other
  • unsure

7. When did the conduct occur? (please provide a date as specific as you can)

__________________________________________________

8. When did you first become aware of the conduct? (please provide a date as specific as you can)

__________________________________________________

9. You need to lodge this application within 6 months of the date at question 8.

If more than 6 months has passed, you will need to ask the agency for special permission to lodge a late application. Please explain why you have taken more than 6 months to make your complaint (for example: I had other urgent priorities - list them, or while the conduct occurred more than 6 months ago, I only recently became aware of my privacy rights, etc)

__________________________________________________

__________________________________________________

10. What effect did the conduct have on you?

__________________________________________________

__________________________________________________

11. What effect might the conduct have on you in the future?

__________________________________________________

12. What would you like to see the agency do about the conduct?

(For example: an apology, a change in policies or practices, your expenses paid, damages paid to you, training for staff, etc)

__________________________________________________

I understand this form will be used by the agency to process my request for an internal review. I understand that details of my application will be referred to the Privacy Commissioner in accordance with: section 54(1) of the Privacy and Personal Information Protection Act; or section 21 of the Health Records and Information Privacy Act; and that the Privacy Commissioner will be kept advised of the progress of the internal review.

Your signature:

__________________________________________________

Date:

__________________________________________________

  • Send this form to the agency you have named at Q.1.
  • Keep a copy for your records
  • For more information on the PPIP Act or the HRIP Act, visit our website: www.ipc.nsw.gov.au