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Data Privacy Consent Form

Uploaded by

Colleen Cristales
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37 views2 pages

Data Privacy Consent Form

Uploaded by

Colleen Cristales
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Legal Unit Priority Number:

DATA PRIVACY CONSENT FORM


To be accomplished
by the Legal Unit
Nature of Transaction (Please check appropriate spaces.) personnel:

REQUEST FOR CORRECTION OF SCHOOL RECORDS Date:


Start:
REQUEST FOR CERTIFICATION AS TO ADMINISTRATIVE COMPLAINT/CASE End:

The said Certification is to be used for (Please check appropriate box.)

Retirement Survivorship benefit

Travel abroad Loan application.

Transfer

Others (please specify) .

To be accomplished before any personal data is disclosed.

I hereby certify that: (a) I have read the Data Privacy Notice of the Legal Unit; (b) I am voluntarily giving the data requested
below; (c) consent is given for the use of the above data in the processing of my above request; (d.) I fully understand that the
data to be given will be made available to the GSIS office in case of retirement or claim for survivorship benefits, or to the
concerned school and Schools Division Office in case of correction of school records, and to other applicable offices or agencies
in relation to my transaction.

For correction of school records: (a) I am voluntarily giving copies of my Certificate of Live Birth and other pertinent documents;
(b) I agree to have said copies retained in the files of the Legal Unit and the Records Section, as well as the concerned school(s)
and Division Office; (c) I understand that these documents are necessary for the processing of my requested change of data.

Name of informant:

Signature: Date:

NOTE: In case the informant is not the student or the student’s parents (for correction of school records), or is not the applicant
for the above-indicated personnel action (for issuance of Certification), or is not the designated Liaison Officer, said informant
must be duly authorized through a Special Power of Attorney.

To be accomplished in relation to requests for correction of data in permanent school records.

Name of student: Sex:

Complete mailing address:

Cellphone number: Email address:

To claim the approved request, please check the preferred box below:

Personal Through mail


To be accomplished in relation to requests for Certification as to administrative complaints/cases.

Name of DepEd personnel: Sex:

For married female personnel, please indicate maiden last name:

Cellphone number: Email address:

Position: Station/School:

Schools District: Schools Division:

FOR RETIREMENT: FOR SURVIVORSHIP BENEFITS:

Effective date of retirement: Date of death:

Name of surviving spouse/heir and relationship to the


deceased:

FOR LEAVE TO TRAVEL ABROAD: FOR TRANSFER:

Personal Official Effective date of transfer:

Dates of travel: New station:

Destination:

To be accomplished by the Legal Unit, Department of Education Regional Office VI


(For request for Correction of School Records and Certification)

Received with complete documents Received, with need to submit additional requirements

Checked by:
Signature over Printed Name

Position/Designation

To be accomplished by the Legal Unit, Department of Education Regional Office VI

No pending administrative complaint/case.

With pending administrative complaint(s).

With pending administrative case(s).

Verified by:
Signature over Printed Name

Position/Designation

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