DATA PRIVACY COMPLAINT FORM

Instructions: Please use this form to report any concerns regarding the processing of your personal data, suspected data breaches, or violations of your rights under the Data Privacy Act of 2012.

Name

First

Last

Relationship to Organization

Contact Number

Date of Incident/Discovery

System Involved (if known)

Nature of Complaint (Check all that apply):

Unauthorized processing or disclosure of my data
Access to my data was denied
My personal data is inaccurate or incomplete
Suspected data breach (loss/theft of device or hacking)
Other:

Complaint (if to

Description of the incident

What action would you like the organization to take?

DECLARATION AND CONSENT

I certify that the information provided is true and correct. I consent to the processing of my data by the Data Breach Response Team for the purpose of investigating and resolving this complaint.

Full Name (Digital Signature)

By typing your name here, you are providing a legal electronic signature.

DATA PRIVACY COMPLAINT FORM

Roots of Health

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