Alder Hey Children's NHS Foundation Trust

Information Request Form

Title (R):

Initial (R):

Surname (R):

Address (R):

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Email (R):

Date Request Made:

4 December 2008

Please describe the information you require: be as specific as possible when telling us what information you require. This will help us to find it. If it is not clear what information you are seeking we may need to get in touch with you. (R)

Please state preferred format of information: i.e. hard copy, electronic copy, large print etc.

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(R) = Required field.

Data Protection
Your completed information request form will be used by the Trust for the purposes of dealing with your information request and sending the information to you at the address given. The information you provide may also be used (with your name and address removed) for the purposes of monitoring and reviewing the types of requests received and the information included in the Trust's Publication Scheme. The Trust is the "data controller" of information you supply on the Information Request Form and any queries you have about this should be directed to the Information Governance Co-Ordinator

If you do not wish to submit this form electronically, it can be completed either on-screen then printed or in writing and returned to:

Paula Fagan
Information Governance Co-ordinator
Royal Liverpool Children’s NHS Trust
Eaton Road
Liverpool
L12 2AP

Email: paula.fagan@rlc.nhs.uk

For Official Use
Date Received:		Request Number:
Date Acknowledged:		Date Responded:

Tel: 0151 228 4811 - Fax: 0151 228 0328
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