Complaints Protocols

COMPLAINTS PROTOCOLS

FORM  5
COMPLAINT REGARDING INTERFERENCE WITH THE PROTECTION OF PERSONAL INFORMATION/COMPLAINT REGARDING DETERMINATION OF AN ADJUDICATOR IN TERMS OF SECTION 74 OF THE PROTECTION OF PERSONAL INFORMATION ACT, 2013 (ACT NO. 4 OF 2013) REGULATIONS RELATING TO THE PROTECTION OF PERSONAL INFORMATION, 2018
[Regulation 7]

Note:
1. Affidavits or other documentary evidence as applicable in support of the request may be attached.
2. If the space provided for in this Form is inadequate, submit information as an Annexure to this Form and sign each page.
3. Complete as is applicable.

Mark the appropriate box with an "x".
Complaint regarding:
Alleged interference with the protection of personal information
Determination of an adjudicator

PART I A

ALLEGED INTERFERENCE WITH THE PROTECTION OF THE PERSONAL INFORMATION IN TERMS OF SECTION 74(1) OF THE PROTECTION OF PERSONAL  INFORMATION ACT, 2013 (Act No. 4 of 2013)

Name(s) and surname/registered name of data subject

Unique Identifier/Identity Number

Residential, postal or business address

Contact number(s)

Fax number/E-mail address

PART I B

PARTICULARS OF RESPONSIBLE PARTY INTERFERING WITH PERSONAL
INFORMATION

Name(s) and surname of adjudicator

Name(s) and surname of responsible party/registered name

Residential, postal or business address

Contact number(s)

Fax number/E-mail address

PART I C

REASONS FOR COMPLAINT

Please provide detailed reasons for the grievance

PART II A

COMPLAINT REGARDING DETERMINATION OF ADJUDICATOR IN TERMS OF SECTION 74(2) OF THE PROTECTION OF PERSONAL INFORMATION ACT, 2013 (ACT NO. 4 OF 2013) A PARTICULARS OF COMPLAINANT

Name(s) and surname/registered name of data subject

Unique Identifier/Identity Number

Residential, postal or business address

Contact number(s)

Fax number/E-mail address

PART II B

PARTICULARS OF ADJUDICATOR AND RESPONSIBLE PARTY

Name(s) and surname of adjudicator

Name(s) and surname of responsible party/registered name

Residential, postal or business address

Contact number(s)

Fax number/E-mail address

PART II C

REASONS FOR COMPLAINT

Please provide detailed reasons for the grievance

Signed at ……………………………………….…… on this ………… day of ………………. 20 …..…

 

……………………………………………………………..
Signature of data subject/designated person