Subject Access Request Form

If you are completing this by hand, please complete the form in BLOCK CAPITALS and in BLACK PEN.

Please tick as appropriate:

☐	I am requesting access to my own personal record.

Please complete sections A, C, D & F.

☐	I am requesting access to records belonging to another living individual. Please complete sections A, B, C, D & F.

☐	I am requesting access to the records of a deceased person.

Please complete sections A, B, C, E & F.

SECTION A – Details of the person requesting the information

Surname	First name(s)
Title (please tick)	Mr ☐ / Mrs ☐ / Miss ☐ / Ms ☐ / Dr ☐ / Other (specify)
Current Address	Previous Address (if applicable)
Postcode	Postcode
Telephone No	Date of Birth

SECTION B – Details of the person whose records you are applying to see

Surname	First name(s)
Title (please tick)	Mr ☐ / Mrs ☐ / Miss ☐ / Ms ☐ / Dr ☐ / Other (specify)
Current Address	Previous Address (if applicable)
Postcode	Postcode
Telephone No	Date of Birth

SECTION C – Details of the record(s) you wish to access

Name of service (if known)
Service received
Approximate date(s)
Key support worker (if known)
Please provide any additional information below about the records you wish to access which may help us to locate it. If we require any further details about the information that you are requesting, we will contact you.

SECTION D – Authorisation and Identification

Please select one of the following options:

☐	I am the person who is requesting their own records

☐	I am the person with parental responsibility / next of kin / carer / advocate for the person named in section B

I am the personal with parental responsibility / next of kin / carer / advocate and manage the person’s affairs and I am acting in the best interests of the person supported

If you select this option, please also confirm one of the following options:

☐	The person supported has consented to me making this request (please enclose written consent from the person supported)

☐	The person supported is incapable of understanding the request

☐	I am acting as an advocate on behalf of the person supported

I have been asked by the person supported to act on their behalf and enclose written and signed authorisation from the person supported

We are committed to ensuring we do not share personal information with people who are not authorised access to it. In some circumstances, we may ask to verify your ID. If asked to provide this, acceptable forms of ID are a copy of your passport, driving licence, Translink Senior Citizen Smart Pass or electoral card.

SECTION E – Requesting Access to the Records of a Deceased Person

Access is only granted to those with parental responsibility / next of kin or the person acting on behalf of the deceased.

☐	I am the personal representative of the deceased person who was supported and I enclose evidence of this from a solicitor.

Date of death:

SECTION F – Cost

Positive Futures gives data subjects or their nominated advocate representative (person with parental responsibility / next of kin / carer / advocate) access to their personal data free of charge within 1 month of receiving a subject access request. Any information relating to a third party is removed from the record before being released, unless the third party has authorised the release of this information. Please note that forms received without the necessary consent / legal documentation will not be processed and will be returned to you.

DECLARATION

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the records / information referred to.

Signature	Date

This completed and signed subject access request form should be returned (with any supporting documentation referred to in sections D or E) to the Information Manager, Head Office, 2b Park Drive, Bangor, BT20 4JZ or via email to info@positive-futures.net.

For Office Use Only
Date form received
Date ID verified (if required)
Date completed

A ‘reasonable fee’ (based on the administrative cost of providing the information) may be charged when a request is manifestly unfounded or excessive, particularly if it is repetitive, and to comply with requests for further copies of the same information.

A further two months may be added where requests are complex and numerous. Where this is the case, the Information Manager must write to the data subject within 1 month explaining why the extension is necessary.