This form, set up within the framework of the General Data Protection Regulation (GDPR), allows you to request information on the processing of your Personal Data managed by CENTRE HOSPITALIER UNIVERSITAIRE DE MARTINIQUE or to exercise your rights on the Personal Data concerning you subject to such processing.

It must be returned signed by e-mail to: This email address is being protected from spambots. You need JavaScript enabled to view it.

I. IDENTIFICATION OF THE APPLICANT*

☐Monsieur ☐Madame

Last name: __________________________________

First name: __________________________________

Email : __________________________________

Phone: _________________________________

Postal address: _________________________________

Applicant profile (Customer, Collaborator) : _________________________________

II. RIGHT INVOKED *

Pursuant to the European Regulation of April 27, 2016 n°2016/679 on the

protection of individuals with regard to the processing of Personal Data and the free

Personal Data and to the free movement of such data, I wish to assert:

☐ Right of access

☐ Right of opposition

☐ Right of rectification

☐ Right to erasure

☐ Right to limitation of processing

☐ Right to portability

You can refer to the EXPLANATORY NOTICE for more details on your rights.

III. SPECIFY YOUR REQUEST (not mandatory)

IV. PROOF OF IDENTITY

☐ I undertake to provide, in addition to this form, a copy of an identity document

identity document enabling the Data Protection Officer to formally

authenticate me formally, if I am not an employee of the CENTRE HOSPITALIER UNIVERSITAIRE DE MARTINIQUE *.

☐ By checking this box, I give my consent for the collection and processing of the Personal Data entered in this form by the CENTRE HOSPITALIER

UNIVERSITAIRE DE MARTINIQUE *.

The information collected on this form is used to process your request and will only be request and will only be kept in case of imperative need of proof. It

is recorded and transmitted to the departments of the CENTRE HOSPITALIER UNIVERSITAIRE DE

MARTINIQUE concerned by your request.

Signed at* :

Date* :

Signature* :

EXPLANATORY NOTE

Right of access: the data subject has the right to obtain from the data controller confirmation from the Data Controller as to whether or not Personal Data concerning him or her is being processed. are or are not being processed, and when they are, access to the said data, specifying the purpose, destination and retention period of such personal data. personal data.

Right to object: the person concerned may at any time object to an organization's to use certain data for a specific purpose. The objection must be

motivated by reasons relating to the particular situation of the person concerned.

Right of rectification: the data subject may request rectification of inaccurate or incomplete

inaccurate or incomplete information relating to the purpose of the processing.

Right to erasure: the data subject has the right to obtain from the Data Controller the deletion of Personal Data concerning him or her. The Data Controller is obliged to carry out this deletion as soon as possible when :

- The Personal Data is no longer necessary for the purposes for which it was collected.

the purposes for which they were collected or otherwise processed otherwise processed;

- The data subject withdraws the consent on which the processing is based

- The data subject objects to the processing;

- The Personal Data has been processed unlawfully;

- Personal Data must be erased in order to comply with a legal obligation

obligation under European Union law or the law of the Member State to which the

to which the Data Controller is subject.

Right to limitation of processing: the data subject has the right to obtain from the

data controller to restrict processing where the following applies

apply:

- The accuracy of the Personal Data is disputed;

- The processing is unlawful and the data subject objects to its erasure

and demands instead that their use be restricted;

- The Data Controller no longer needs the Personal Data for processing purposes

for the purposes of processing, but it is still necessary for the person concerned to

concerned for the establishment, exercise or defense of legal claims

in court;

- the data subject has objected to the processing.

Right to portability: data subjects have the right to receive the personal data they have

personal data that they have supplied to a Data Controller, in a structured format in a structured, machine-readable format, and have the right to have this data to transmit such data to another controller without the controller to whom the data controller to whom the Personal Data has been communicated.

data has been communicated. When the data subject exercises his/her right to to data portability, he or she has the right to obtain that the Personal Data be directly from one Data Controller to another, where technically possible.