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Written Request Form

Instructions: This form helps you to submit a formal written request to The Office of the Privacy Commissioner for Bermuda (“PrivCom”), if you have concerns about how an organisation is using or has used personal information in accordance with the Personal Information Protection Act 2016 (“PIPA”).

 

If you need any extra support with completing this form and/or understanding your rights under PIPA, please contact our Investigations Unit: investigations@privacy.bm or (441) 543-7748

 

Privacy Notice: Following submission of a formal written request to PrivCom, we shall provide a copy of your written request to the organisation concerned and any other person considered appropriate. PrivCom may redact any information contained in the formal written request that is considered appropriate, prior to providing a copy of the formal written request to the organisation or any other individual affected by the written request.

1. I am contacting The Office of the Privacy Commissioner for Bermuda:
On behalf of myself
On behalf of the Applicant
2. Does your written request to PrivCom concern Personal Information?
Yes
No
3. (a) Have you submitted a PIPA Rights Request to the Organisation? (If no, please continue to question 4)
Yes
No
(b) What type of PIPA Rights request did you submit to the organisation?
A request to access my personal information
A request to access my medical records
A request to correct, block, erase, or destroy my personal information
(c) Have you allowed the organisation forty-five (45) calendar days or the extended timeframe to provide a response?
Yes
No
4. (a) Have you raised a complaint with the organisation ?
Yes
No
(b) If no, please confirm that you agree to PrivCom sharing the complaint with the organisation.
Yes
No

  1. What is your reason for contacting PrivCom?

My written request relates to a review and:
The organisation acknowledged my PIPA Rights request but has not provided any further response
The organisation failed to respond to my PIPA Rights request within forty-five (45) calendar days
The organisation notified me of an extension to my written request but has not provided any further response

OR

My written request relates to a complaint and:
I am not satisfied with the organisation’s response
I am not satisfied with the outcome
I believe the organisation has withheld and or redacted some of my personal information
The organisation has refused my PIPA Rights request due to relying on an exemption or exclusion
I believe the organisation has: lost, destroyed, accessed, used, modified, or disclosed my personal information without my knowledge, approval and/or consent
Other

  1. Applicant Details:

9. Organization Details:

10. Authorized Party on behalf of Applicant:

Please attach copies of the following documents if you have them:

By submitting this written request:

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