Sample CCTV Access Request Form Template

Confidential — for internal use only

Please complete all sections of this form and submit it to the School Office or email to: ___ [School contact email] ___
The School will assess your request in line with its CCTV Usage Policy, Privacy Policy, and Incident Access Protocol.

Note: Submission of this form does not guarantee access. Requests will be reviewed on a case-by-case basis.

1️⃣ Applicant Details

Full Name: _____________________________________________

Organisation (if applicable): _____________________________

Relationship to the School (please tick):
☐ Parent/Guardian of a student
☐ Staff member
☐ Law enforcement agency
☐ Other (please specify): _________________________________

Contact Phone Number: _________________________________

Email Address: ________________________________________

Postal Address (optional): _______________________________

2️⃣ Incident Details

Please provide as much detail as possible about the incident you are referring to.

Date of Incident: ___ / ___ / ______

Time of Incident (approximate): _________________________

Location of Incident (specific area): ______________________

Names of individuals involved (if known): ________________

Description of Incident:

Reason for Requesting Access to Footage:

3️⃣ Type of Access Requested

☐ To view footage at the School under supervision.
☐ To receive a copy of the footage (if permitted under law and School policy).

4️⃣ Declaration

By signing below, I declare that:
✅ The information I have provided is true and correct to the best of my knowledge.
✅ I understand that CCTV footage may contain images of other individuals whose privacy rights must be protected.
✅ I agree to use any footage provided only for the stated purpose above and in accordance with applicable privacy laws.
✅ I understand that the School reserves the right to refuse access if it would breach privacy or legal obligations.

Signature: _____________________________________________

Date: ___ / ___ / ______