Request for Security Report or CCTV Footage

Before proceeding with your CCTV footage request, please be aware that we only review and release footage for specific security reasons. These include situations involving potential harm to our patients, medical staff, or employees, as well as the investigation of criminal activities, incident investigations, compliance and regulatory inquiries, verification of events, and security threats. We cannot process requests related to personal or missing items. Reviewing CCTV footage requires significant time and manpower. If you wish to request footage outside of our policy, you will be charged based on the man-hours required to retrieve the video, and the request must be approved by the Data Protection Officer (DPO). Payment for such requests will be directed to the CCTV Command Center under the Office of Facilities and Management.

In adherence to the Data Privacy Act of 2012 (Republic Act No. 10173) and its implementing rules and regulations, this form facilitates the consent and waiver required for obtaining security reports or CCTV footage from the Chinese General Hospital and Medical Center (“CGHMC”).

Step 1 of 2

Part I: Requestor Information

Name(Required)

First Last

Mobile Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Purpose of Request:(Required)

Please provide specific details regarding the purpose of your request, as this is necessary for compliance with the Data Privacy Act of 2012.

Part II: Description of Request

Time(Required)

Specific time of the incident

Date(Required)

Specific time of the incident

Location/Area within CGHMC Premises:(Required)

Specific location of the incident at CGHMC

Description of Incident/Event:(Required)

Please provide a detailed description of the event or incident.

Part III: Consent and Waiver

Upload and Valid ID(Required)

The purpose of uploading your valid ID is to verify that you, as the data subject, are the one making the request. The uploaded ID will be automatically destroyed and properly disposed of in accordance with the Data Privacy Act of 2012 within one year of your request. It will be retained solely for audit trail purposes to ensure legal compliance.

Max. file size: 2 MB.

Signature(Required)