Data Protection and privacy complaint form

If you are concerned that your personal data has not been handled in accordance with the Monash University Data Protection and Privacy Procedure, the relevant Collection Statement(s) and/or your individual rights, you may lodge a written complaint to the University’s Data Protection and Privacy Office by completing this form and sending it to dataprotectionofficer@monash.edu.
To make a complaint, we require your name and a method of contacting you (preferably an email address or postal address). 
•	Your personal data is collected on this form to assist the University’s Data Protection and Privacy Office to respond to your concerns.
•	You are welcome to contact the University’s Data Protection and Privacy Office anonymously to make an enquiry or discuss data protection or privacy issues. However if you do not wish to provide your personal data, the Data Protection and Privacy Office may be limited in the assistance it is able to provide to you. 
•	Details of the complaint may be conveyed to the relevant faculty or division of the University and/or individuals named in the complaint, so that the substance of the complaint can be appropriately investigated. Details may also be disclosed to other parties who may have information relevant to the complaint and its investigation.

We will acknowledge receipt of your complaint. You do not need to do anything further until a member of the University’s Data Protection and Privacy Office contacts you.

YOUR COMPLAINT
SECTION 1 – YOUR CONTACT DETAILS	
Title:	  Mr		  Ms		  Mrs		  Miss	
  Other, please specify	
Full Name: 		
Postal Address: 
(if applicable)		
Email:		
Phone:
(if applicable)		
Preferred method of contact:	  Telephone	  Mobile		  Email		  Mail	
Please indicate which of the following applies:
	  Current Staff Member		  Past Staff Member	
  Current Student			  Past Student		
  Other (please specify)		
SECTION 2 – COMPLAINT DETAILS - The clearer your explanation is, the more easily we will be able to assist you. Please feel free to attach additional information.	
Date issue occurred	        /        /          	Date you became aware of the issue	        /        /          	
Personal information involved	
  Name		  Email Address		  Username	
  ID Number		  Telephone Number	  Home Address		
  Date of Birth			
  Other, please specify	

Sensitive Information involved	
  Racial or Ethnic Origin	  Political Opinions	  Membership of a political association	
Religious beliefs or affiliations	  Philosophical beliefs	  Membership of a professional or trade association	
  Membership of a trade union	  Sexual preferences or practices	  Criminal record			
Health Information involved	
  Medical information	  Mental health information	  Disability related information	
  Physical health information	  Genetic information	  Use and future use of health services		
  Wishes regarding specific health services or treatments		  Other, please specify			
How do you believe your privacy has been compromised, having regard to the Information Privacy Principles and Health Privacy Principles?

	
Please outline what occurred? Include details of when it occurred and how it occurred.

	
Who was involved? (include names of individuals involved if known)

	
How did you become aware of the issue?

	
Other

	
SECTION 3 – Supporting Information	
Attach copies of any documents about your complaint (for example any correspondence you may have already had with Monash University regarding this matter).

	
SECTION 4 – What Resolution are you Seeking?	
What are you seeking from Monash University to resolve your complaint?	
SECTION 5 – Date	
Date