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G 020 Form 2 Data Subject Privacy Consent Form Fill in

This document is a data subject privacy consent form used by Mariano Marcos Memorial Hospital and Medical Center (MMMH&MC). It details how MMMH&MC will collect, use, and protect employees' personal and sensitive personal information for the purpose of including it on official identification cards. The form lists the specific information that will be collected, including TIN number, PhilHealth number, address, contact details, and emergency contact information. MMMH&MC agrees not to disclose this personal information without written consent and the data subject agrees to allow their information to be collected and processed for this legitimate purpose.

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Aimee Hugo
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78 views2 pages

G 020 Form 2 Data Subject Privacy Consent Form Fill in

This document is a data subject privacy consent form used by Mariano Marcos Memorial Hospital and Medical Center (MMMH&MC). It details how MMMH&MC will collect, use, and protect employees' personal and sensitive personal information for the purpose of including it on official identification cards. The form lists the specific information that will be collected, including TIN number, PhilHealth number, address, contact details, and emergency contact information. MMMH&MC agrees not to disclose this personal information without written consent and the data subject agrees to allow their information to be collected and processed for this legitimate purpose.

Uploaded by

Aimee Hugo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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MMMHMC-A-HRM-G-020-Form2 Rev.

0- Data Subject Privacy Form

DATA SUBJECT PRIVACY CONSENT FORM

DATA SUBJECT PRIVACY CONSENT FORM

Name of Data Subject:

(Last Name) (First Name) (Middle Name)

This document gives details on how MMMH&MC uses and protects personal data for the purpose of obtaining the
consent of data subjects, in pursuant with Republic Act 10173 also known as the Data Privacy Act of 2012, its
Implementing Rules and Regulations, and other relevant laws of the Philippines.

I. About Personal Data


1. Personal information refers to any information whether recorded in a material form or not, from which
the identity of an individual is apparent or can be reasonably and directly ascertained by the entity
holding the information, or when put together with other information would directly and certainly identify
an individual.

2. Sensitive personal information refers to personal information:


(a) About an individual’s race, ethnic origin, marital status, age, color, and religious, philosophical or
political affiliations;
(b) About an individual’s health, education, genetic or sexual life of a person, or to any proceeding for
any offense committed or alleged to have been committed by such person, the disposal of such
proceedings, or the sentence of any court in such proceedings;
(c) Issued by government agencies peculiar to an individual which includes, but not limited to, social
security numbers, previous or current health records, licenses or its denials, suspension or revocation,
and tax returns; and
(d) Specifically established by an executive order or an act of Congress to be kept classified.

II. Purpose: This is for the purpose of gathering the relevant Personal Information and Sensitive Personal
Information of Mariano Marcos Memorial Hospital and Medical Center (MMMH&MC) Employees to be
indicated in the official MMMH&MC official Identification (ID) Card.

III. Type of Personal Data Collected: MMMH&MC may collect the following Personal Information and
Sensitive Personal Information:
1 TIN No.
2. PhilHealth No.
3. GSIS No.
4. PAG-IBIG No.
5. Birthdate
6. Address
7. Contact No.
8. Blood Type
8. Person to notify in case of emergency, the address and contact number
9. Employee’s specimen signature

IV. Confidentiality of Data: MMMH&MC shall not disclose or share personal information in its possession
other entries without your expressed written consent.

V. Consent: I have read this form and understand its content and voluntarily give my consent to allow my
personal/sensitive personal information to be collected, use, processed, for the above specific and
legitimate purpose. I also understand that my consent does not prevent the existence of other criteria for
lawful processing of personal data and does not waive any of my rights under Republic Act 10173.

Data Subject signature over printed name Position and Department Date and Time
signed

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