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Written Request Form

Instructions: This form helps an individual to submit a written request to The Office of the Privacy Commissioner for Bermuda (“PrivCom”); in accordance with the Personal Information Protection Act 2016 (“PIPA”). A written request assists an individual to raise concerns about an organisation’s overall compliance with Part 3 of PIPA (Rights of Individuals). The outcome focuses on ensuring the organisation’s compliance with Part 3 of PIPA and provides a specific remedy to an individual.

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If extra support is needed to complete this form and/or understanding individuals’ rights under PIPA, please contact PrivCom’s Investigations Unit: investigations@privacy.bm or (441) 543-7748.

 

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

1. I am contacting The Office of the Privacy Commissioner for Bermuda:
On behalf of myself
On behalf of the applicant

You must have authority, along with supporting documents, to make a request for someone else.

2. Does your written request to PrivCom concern Personal Information?
Yes
No

If you select 'No', PIPA only applies to use of personal information. You may need to submit a General Non-Compliance written request.

3 (a). Have you submitted a PIPA Rights Request to the Organisation?
Yes
No

A PIPA rights request must first be made to the organisation, prior to submitting a written request to PrivCom. How do I submit a PIPA Rights Request?

3 (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
4. Did the organisation provide a response to your PIPA Rights Request?
Yes
No

  1. Applicant Details:

Please indicate the best time to contact you, as well as any other contact restrictions. PrivCom office hours are Monday to Friday, from 9:00 a.m. to 5:00 p.m. AST

Multi-line address

  1. Organization Details:

Multi-line address

  1. Authorized Party on behalf of Applicant:

You must have signed written permission, along with supporting documents (if applicable), to make a request for someone else.

Multi-line address

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

By submitting this written request:

**If you do not agree with either of the above, PrivCom will consider the request invalid, and will not proceed with this matter.**

Date of Submission
Day
Month
Year
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