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Complaint Details

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A. PARTICULARS OF THE COMPLAINANT/REPRESENTATIVE

Indicate whether you are filing as self or on behalf of other individual(s)

Proof of authorization

First Name

Surname

Other

Complainant’s National Identification Card Number/Passport

Telephone No/Mobile No where complainant can easily be reached

Postal Address

Physical address or location (for statistical purpose only)

Complainant Email Address

Preferred Mode of Communication

Select the type of document to upload

Upload ID Front (PDF, JPG, PNG, JPEG)

Upload ID Back (PDF, JPG, PNG, JPEG)

B. PARTICULARS OF THE RESPONDENT

Name of respondent

Contact details of the respondent (Individual or Institutional):

C. PARTICULARS OF THE COMPLAINT

Date of occurrence of the alleged infringement

Describe your complaint

Any actual or potential harm or any urgency to be taken note of:

The name (s) of any persons that can provide further information relevant to the complaint, if any;

D. REMEDY SOUGHT

State in your view what redress/relief you are anticipating:

Which other steps have you already taken in relation to the complaint; if any

Particulars of any person or institution that has previously made attempts to resolve the matter:

In the event that the Respondent is contacted, do you wish to remain anonymous?

Yes

Do you wish to provide any evidence or supporting documents?

I confirm that the information provided here is accurate

Please preview your details

Application for Alternative Dispute Resolution

Purpose:

To apply for Alternative Dispute Resolution proceedings in accordance with the procedures contemplated in:

Constitution of Kenya, 2010; Article 159 (2) (c).
Section 9(1)(c) of the Data Protection Act, 2019.
Data Protection (Complaint Handling Procedure and Enforcement) Regulations, 2021.
Office of the Data Protection Commissioner ADR Framework.

Notes:

Where the space provided is insufficient, please make use of an extension page and attach it to this form.
Pages attached are to be sequentially numbered, and the total number stated in the provided field.
Please note that you may select more than one box.
The completed form and attachments are delivered to the Data Protection Dispute Resolution Registry or emailed to ADR@ODPC.GO.KE.

A: Details of Complainant (For purposes of further correspondence)

Full Name(s)	Telephone No.	Name of Agent (if not applicant)	Telephone No.	Email Address

B: Address for delivery of documents

Registered business name or name of Respondent/Agent
Postal Address		Code
Physical Address
Email Address
Business Telephone Number

C: Status of dispute

Is the dispute	Lodged with ODPC	Complaint Number
Is the dispute	In Court (High Court or Court of Appeal)	Court Reference Number
If "Other", please specify

D: Nature of Dispute

Nature of dispute:(Kindly give a brief description of the Dispute if not already lodged with ODPC)

E: Grounds for Application

Grounds for ADR Application

F: Please attach appeal documents

(Memorandum of Appeal, Statement of Facts,Commissioner's decision appealed against and any other relevant documentation')

Upload Appeal Documents

G: Please attach a settlement proposal(if any)

Upload Settlement Proposal

H: No. of pages attched to this form(if any)

No. of pages attached to this form

I: Declaration

I hereby apply that the above matter be admitted for resolution through the Alternative Dispute Resolution process and declare that;

I have fully stated the ground upon which ADR is being applied for; and
I have provided/attached relevant documentation in support of my application.

J:Completed by:

Full Name (s)

Title

Date