ESTATES AND FACILITIES DIVISION
FACILITIES SERVICES
RECORDS OFFICE
Gower Street, London WC1E 6BT
DATA PROTECTION
form 4
Request to withhold the publication of personal information by UCL
The Data Protection Act (1998)
With reference to the Data Protection Act ( 1998), UCL will publish personal
information including names, departmental affiliations, Email addresses
and telephone extensions on the UCL World Wide Web Facility unless the
individual concerned specifically requests that these be withheld.
UCL may also publish photographs or digital images of individuals, either
for identification purposes or to publicise College or Departmental events
unless the individual concerned specifically requests that these be
withheld.
You are at liberty to request removal of your personal information at any
time.
No other personal information will be divulged.
If you wish your personal information to be withheld, please complete the slip
below and return to:
Mrs. R.H. Cummings, Records Manager & Data Protection Officer, UCL
Records Office.
Unless the slip is returned, UCL will assume that you consent to the
information being published on the WEB, and to your photograph or
digital image being published.
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FULL NAME: _____________________________
(BLOCK CAPITALS)
DEPARTMENT: _____________________________________
(BLOCK CAPITALS)
DATE OF BIRTH: ___________________ ( for easy identification)
I do not wish UCL to publish my name and Email address on the UCL
World Wide Web Facility. Please tick _________
I do not wish UCL to publish or display my photograph or digital image.
Please tick _________
Signed:________________________
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Date:_________________
__________________________________________________________
For Office use:
Date received by Data Protection Officer ___________ Signature
_____________________
Date central file updated by
Registrar’s Division Signature
_____________________
or
Department Signature
_____________________
Management Systems Division ___________ Signature
_____________________
Date copy of this form returned to Signature
member of staff/student concerned ___________ of DPO
_____________________
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