RFI

Your information

For your request to be dealt with under Freedom of Information, please give your name and contact information below. Please note, this form is not to be used for requesting medical records. If this information is required, please go back into the Trusts website and using the 'search bar', input "request medical records".

Complainant Code

Person Search

Link ID

First Name / Surname

NHS Number (if this applies to a patient)

ID1

Title

Date of Birth

Patient Deceased

Date Died. If this query concerns a deceased patient, another process must be followed

Ethnicity

Type of Person

Address

Post Code

Telephone

Your details, as you have indicated you are not the Patient

Please attach a copy of the patient’s written consent/legal document authorising you to request information on behalf of the patient.

Requester Code

Company Name

Person Deceased

Date Died

Person Search

Link ID

NHS Number

ID1

First Name / Surname

Title

Date of Birth

Ethnicity

Select the option which best describes you

Address

Post Code

Telephone

Reporter

Person Reporting

The field above is for the Staff Lookup

Staff Id

Surname

First Name

Job Title

Job Status

Organisation

Site

Department

Directorate

Contact No.

Ethnicity

Email Address

Contact Details

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Post Code

On Behalf of (Staff)

Staff Id

Surname

First Name

Job Title

Job Status

Organisation

Site

Department

Directorate

Contact No.

Ethnicity

Email Address

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Post Code

Request DetailsMore

Please complete all relevant fields, the ones in orange are mandatory and MUST be completed for this form to be saved.

Type of Request

Date Received

Method Received

Time Received

Request Date

Response Due Date

Acknowleged

Brief summary of your request

Organisation

Details of Request and information required

Extension Reason

Response Format Required

Response Date

Handler

Your Job Title

Your Company

Type of Organisation

Estimate Of Time (hrs)

Estimate Of Time (mins)

Status

Request wide location info

Organisation

Locality 2

Locality 3

Site

Site Type

Department

Specialty

Locality 1

Locality 2

Please detail your request for information below

Click the NEW button for each individual question you would like to request information for. Please note that in order for us to be able to process your request for information, please clearly document what information you are after with any additional information such as time frames.

Specialty (if known)

record	unique	Question?	Del.

Please attach any relevant templates or documentation to your request. Please note that we are unable to process any documents that are saved as a pdf

Add Attachments

Document	Date Added	Time Added	Entered By	Delete

Please verify you are human by entering the letters and numbers from the picture into the box below.

Workflow /

Submit Request