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Request for an Internal Review form, Privacy UTS

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					REQUEST FOR AN INTERNAL REVIEW
PRIVACY CONTACT OFFICER, GOVERNANCE SUPPORT UNIT
Level 26, Building 1, Broadway, City campus, telephone 9514 1225, fax 9514 1232



 Application for and Internal Review under Section 53 of the Privacy and Personal Information Protection Act 1998 (NSW) and Section 21
 of the Health Records and Information Privacy Act 2002 (to be undertaken in accordance with the provisions of Section 53 of the Privacy
 and Personal Information Protection Act 1998 (NSW)).



 1. FACULTY / UNIT NAME
 Name of the Faculty or Unit where
 the complaint has arisen



 2. APPLICANT'S DETAILS
 Your full name

 Your postal address
                                         _______________________________________________________________________________________________________


                                         _______________________________________________________________________________________________________


                                         _______________________________________________________________________________________________________
                                         CITY                                             STATE                                POSTCODE


                                         _______________________________________________________________________________________________________
                                         COUNTRY



 3. APPLYING ON BEHALF OF ANOTHER PERSON

 If this complaint is being made on behalf of another person, please provide the following information:

 The other person's full name

 Your relationship to that person

 Is the other person capable of           Yes
 making the complain themselves?
                                          No
                                          I'm not sure



 4. ACTION OR DECISION

 What action or decision do you wish
 to complain about?                      _______________________________________________________________________________________________________


                                         _______________________________________________________________________________________________________


                                         _______________________________________________________________________________________________________


                                         _______________________________________________________________________________________________________


                                         _______________________________________________________________________________________________________


                                         _______________________________________________________________________________________________________


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REQUEST FOR AN INTERNAL REVIEW


 5. TYPE OF COMPLAINT — 'PERSONAL' INFORMATION

 Which of the following items best      Collection of my personal information
 describes your complaint:
                                        Security or storage of my personal information
                                        Refusal to let me access or find about about my personal information
                                        Accuracy of my personal information
                                        Use of my personal information
                                        Disclosure of my personal information

 If there are any other issues
 involved in your complaint, please    _______________________________________________________________________________________________________
 provide information about those
 issues here:
                                       _______________________________________________________________________________________________________


                                       _______________________________________________________________________________________________________



 6. TYPE OF COMPLAINT — 'HEALTH' INFORMATION

 Which of the following items best      Collection of my health information
 describes your complaint:
                                        Security or storage of my health information
                                        Refusal to let me access or find about about my health information

                                        Accuracy of my health information
                                        Use of my health information
                                        Disclosure of my health information

 If there are any other issues
 involved in your complaint, please    _______________________________________________________________________________________________________
 provide information about those
 issues here:
                                       _______________________________________________________________________________________________________


                                       _______________________________________________________________________________________________________



 7. TIME OF ACTION / DECISION

 When did the action occur, or was
 the decision made?
 Please be as specific as possible.

 When did you become aware of this     Date?
 action or decision?

 Note: You must request permission to lodge a late application if more than six months has passed since the date you provided in the above question.

 If more than six months has passed,
 please provide information about      _______________________________________________________________________________________________________
 why this complaint was not made
 earlier.
                                       _______________________________________________________________________________________________________


                                       _______________________________________________________________________________________________________




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Privacy, Governance Support Unit, November 2004
REQUEST FOR AN INTERNAL REVIEW


 8. EFFECT OF ACTION / DECISION

 What effect did the action or
 decision have on you?                  _______________________________________________________________________________________________________


                                        _______________________________________________________________________________________________________


                                        _______________________________________________________________________________________________________


 What effect may the action or
 decision have on you in the future?    _______________________________________________________________________________________________________


                                        _______________________________________________________________________________________________________


                                        _______________________________________________________________________________________________________



 9. REQUEST FOR UTS RESPONSE
 What action would you like to see
 the University take about the action   _______________________________________________________________________________________________________
 or decision?
                                        _______________________________________________________________________________________________________


                                        _______________________________________________________________________________________________________



 10. PROVIDE COPY OF COMPLAINT TO NSW PRIVACY COMMISSIONER

 Please indicate whether you would       A complete copy of this Request for an internal review form
 prefer that the NSW Privacy
                                         A copy of only the sections numbered 3, 4, 5, 6, 7 and 8 on this form
 Commissioner is given:



 11. DECLARATION

 I understand that this Request for an Internal Review Form will be used by UTS to process my request. I also understand that the details of the
 application will be referred to the NSW Privacy Commissioner in accordance with Section 54(1) of the Privacy and Personal information Protection Act
 1998, and that the Privacy Commissioner will be kept advised of the progress of the review by UTS.


 Signature




 Date

 Time



 LODGING FORM

 When completed, forward this           Director
 Request for an internal review         Governance Support Unit
 form to:                               University of Technology, Sydney
                                        Level 26, Building 1,
                                        City Campus
                                        Broadway NSW 2007



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Privacy, Governance Support Unit, November 2004

				
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