ANNEXES

Annex “A” – Consent Form

PERSONAL DATA
PROCESSING CONSENT FORM

I, , of legal age, and an officer/employee of

the (Agency/Office/Unit), after having read and
understood the Municipality Privacy Manual [or Privacy Policy], do hereby state as
follows:

1. I hereby grant my consent to the collection, recording, retention, use, storage,

updating, modification, and processing by the municipality of my personal and sensitive
personal information (“Personal Data”) which were provided by, or about, me, before or
during the course of my request with the municipality, for the purposes set out in the
Privacy Policy, and all other legitimate purposes that are necessary or incidental to the
same, or are necessary or related to my request with the municipality;

2. I hereby grant my consent to the (a) disclosure by the municipality of my Personal

Data to the other government agencies, third parties or entities identified or contracted
by the municipality and (b) their processing of my Personal Data, for the purposes
described in the Privacy Policy or Privacy Manual for the purposes that are necessary
or incidental to the same, or are necessary or related to my inquiry/request with the
municipality, or are necessary or related to the operations and functions of the
municipality as a data bank of the CBMS data;

4. I hereby grant my consent to the storage and retention by the municipality of my

Personal Data throughout the retention period prescribed by law, rules and
regulations, or policy of the municipality, and to the proper and safe disposal and
destruction by the municipality of my Personal Data, whether in paper or electronic
format, upon expiration of the retention period;

5. I acknowledge and agree that the municipality has put in place appropriate
organizational, physical, and technical security measures to protect the privacy of my
Personal Data. I am also aware that notwithstanding the said privacy protection
measures that have been put in place by the municipality, there is a risk that my
information may be subject to unauthorized disclosure, processing, or breach. I agree
to hold the municipality, its officers, and employees free and harmless from any
damage, loss, liability or injury that I may suffer on account of any unauthorized
disclosure, processing or breach of my Personal Data, provided that there is no bad
faith or gross negligence on the part of the municipality or any of its respective
officials, employees or agents who directly process my Personal Data;

6. I also confirm that I will keep my Personal Data, as recorded with the municipality,
updated whenever necessary.

7. This consent shall be effective for the entire duration of my inquiry/request with the
municipality unless otherwise required by the functions and operation of the
municipality as a data bank of the CBMS data.

IN WITNESS WHEREOF, I have set my hand this day of ,

, in <City/Municipality>, <Province>, Philippines.

Name and Signature

 Annex “B” – Inquiry Summary Form

In certain circumstances, privacy laws provide individuals with certain rights in relation
to the personal data that the <City/Municipality> processes, including the limited right
to receive information about how we process your personal data. To exercise your
rights under applicable data privacy law or make privacy related inquiry, please
complete this Privacy Inquiry Summary Form.
Please note that you will be asked to provide proof of your identity and your request
will be processed within 30 calendar days of our receipt of a fully completed form and
proof of identity. Please note the next steps and directions at the end of the form.
The information you supply in this form will only be used for the purposes of
identifying the personal data you are requesting and for responding to your request.
You are not required to complete this form to make a request, but doing so will make
it easier for us to process your request quickly.

Please note the next steps and directions (Section 3) at the end of this form.

Section 1: Details of the requestor

Full Name (required)

Agency/Office/Unit (required)
Address (required)

Contact Number (required)

Email address

Section 2: What is your relationship to the City/Municipality of <City/Municipality

name>?

 Current employee
 Former employee
 Barangay Unit
 Others (pls. specify)

Section 3: Are you the Data Subject? Please tick the appropriate box and read the
instructions that follow it.

 YES: I am the Data Subject. I have enclosed proof of my identity*, as outlined

below.

(Please go to section 5)

 NO: I am acting on behalf of the Data Subject. I have enclosed proof of my

identity, proof of the Data Subject's identity* and approval from the data subject
to make the request on their behalf.

(Please go to section 4)
*Proof of identity:

To ensure we are releasing data to the right person, we require you to provide us with
proof of (1) your identity and (2) your address. Acceptable forms of proof include a
photocopy of: driver’s license, or national identity card or any valid identification cards
that proves identity of the person. A proof of Formal Authorization Letter or Special
Power of Attorney must be provided.

Note: If we are uncertain that you are who you claim to be, we reserve the right to ask
for additional information, or to refuse to grant your request. If you provide copies of
identification that include sensitive personal information (e.g., social security
number, passport number), please encrypt the file before emailing, or send by
other secure means.

Section 4: Details of the data subject (if different from section 1)

Full Name (required)

Agency/Office/Unit (required)

Address (required)

Contact Number (required)

SECTION 5: Please detail your request or inquiry below.

Is there specific data you are inquiring about? Please understand that accessing your
data does not include the right to access every document, email, or other record, in its
entirety that includes your personal data. For example, you will not receive copies of
every email that includes your name.

SECTION 6: Directions

1. Please fill up and sign this form completely.

2. If the information you request reveals details directly or indirectly about another
person, we will redact that information, or we may seek the consent of that person
before we can let you see that information.
3. In certain circumstances, we may deny your request, or may not be able to disclose
information to you, in which case you will be informed promptly and given reasons for
that decision.
4. While in most cases we will be happy to provide you with copies of the information
you request, we nevertheless reserve the right to charge a fee or refuse the request,
to the extent permitted under applicable law. However, we will make every effort to
provide you with a satisfactory form of access or summary of information if suitable.
5. The information provided will be used for processing Data Subject requests. The
provision of personal data is voluntary. However, if you do not provide sufficient
information, we cannot process your request.
6. If the request is made by an individual other than the Data Subject, an authorization
letter signed by the Data Subject and information that can provide proof of the identity
 of the Data Subject and further proof of the Requestor’s status as a relevant person
should be enclosed.
7. You may be asked to provide additional information to help us process your request,
and you are required to provide proof of identity.

SECTION 7: Declaration

Please note that any attempt to mislead the municipality may result in prosecution.

I confirm that I have read and understood the terms of this Privacy Inquiry
Summary Form and I certify that the information given in this application to the
Municipality of <City/Municipality> is true. I understand that it is necessary
for LGU of
<City/Municipality> to confirm my and / or the data subject’s identity and it may be
necessary to obtain more detailed information to locate the correct personal data. I
further understand that for this inquiry to be processed by the municipality, I must
provide proof of my identity.

Name & Signature Date

Annex “C” – Access Request Form

ACCESS REQUEST FORM

NAME: (First Name, Middle Name, Surname) POSITION:

OFFICE/AGENCY/UNIT:

CURRENT ADDRESS:

Documents Requested (Please check) Purpose of Request (Please check)

List of the Household Members Per Barangay Development Planning
Household BDRRM Planning
List of Number of Households in Relief Operations
Barangay Profiling
Health & Maternal Category Planning (pls. specify)
Water & Sanitation Category
Agricultural Category Other purposes (pls. specify)
MDRRM Category
Social & Protection Category
Crime Victimization Category
Certified true copy/ies of
document/s (Please specify)
Other Documents to be requested
(pls. specify)
Requested by: Approved by: Released by: Documents Received
by:

Signature over Printed name Signature over Printed name Signature over Printed name Signature over Printed name
Date: Date: Date: Date:
 Annex “D” – Privacy Notice

PRIVACY NOTICE

The Local Government of <City/Municipality> is committed to protecting the

privacy rights of individuals on personal data pursuant to the provisions of RA
10173 or the Data Privacy Act of 2012, and its Implementing Rules and
Regulations (IRRs).

Any and all processing of personal data by the municipality shall be made for a
legal purpose and/or pursuant to a legal obligation under applicable laws taken
into consideration and implementing appropriate security measures to ensure
the confidentiality and/or integrity of the personal data involved.

Any and all personal data related to any client which may come into possession
of the municipality and/or control shall be used for legitimate and government-
related purposes. The office shall process clients’ personal data in order to,
among others: (1) comply with applicable laws and legal obligations; (2)
respond to other governmental inquiries or requests from public authorities; (3)
comply with valid legal processes issued by government authorities; (4) protect
the rights, privacy, safety, or property of the municipality, its employees, or the
general public; (5) permit the Office to pursue available remedies or limit the
damages that the Office may sustain; (6) respond to an emergency; and/or (7)
monitor and comply with applicable laws, regulations, policies, and procedures.

The LGU of <City/Municipality> shall retain clients’ information indefinitely, or

until the declared, specific, and legitimate purpose has been achieved or the
processing relevant to the purpose has been terminated. Should there occur an
instance of personal data breach, the Data Privacy Office shall take all
necessary measures to prevent further damage to the clients and/or the Office
which include the following, among others: (1) report the breach to the
Municipality’s Data Protection Officer within 24 Hours; (2) deploy data breach
response team to assess the damage of breach incident, contain breach
incident, and restore integrity to the information and communication system; (3)
inform all affected clients of the breach incident; and (4) mitigate any other
possible harm and/or negative consequence to clients.

The LGU-<City/Municipality> intently upholds the rights of the data subject. The
municipality shall acknowledge any clients’ request to (1) access their provided
personal data; (2) object the collection of personal data; (3) erase or block any
personal data; (4) claim compensation due to damages provided that the office
is proven to have been neglectful in the processing of personal data; and (5) file
a complaint to the office for any mishandling, misuse, malicious disclosure,
and/or improper disposal of personal data.

Should the client have any inquiry regarding the collection of personal data by
the municipality, the DPO is available for contact through the following email at
<email address of DPO>.
 Annex “E” – Request for Correction/Erasure Form

REQUEST FOR CORRECTION/ERASURE FORM

NAME: (First Name, Middle Name, Surname) POSITION:

OFFICE/AGENCY/UNIT:

Request for Correction Erasure

Original Entry Proposed Correction

Name
Birthdate
Status
Address
Telephone Numbers
Others (Please specify)

Reason/s for Correction Erasure

Requested by: Approved by: Released by: Documents Received

by:

Signature over Printed name Signature over Printed Signature over Printed name Signature over Printed name
name
Date: Date: Date: Date: