Individual Privacy Rights Request

Title

First Name *

Middle Name / Initial

Last Name *

Address Type *

Please enter your permanent mailing address

Address 1 *

Address 2

City *

State *

Zip *

Email *

Enter "N/A" if the Requester does not have an email address.

In what capacity are you making this request? * Patient (An individual who has taken, or presently takes, a GSK prescription medicine or vaccine.) Consumer (An individual who has used, or presently uses, a GSK over-the-counter product or service.) Research subject Healthcare professional Supplier/Vendor Other

Select those values that apply to your request.

Please select the individual right(s) you would like to exercise * Right to access

I would like to know what personal information GSK collects and holds on me

Right to delete

I would like to have all of my personal information deleted

*Preferred Contact Method?*

If we need additional information to process your request, how would you like to be contacted?

Email

Please ensure you have entered your email address correctly.

Phone

Please ensure you have entered your phone number correctly.

Other

Please enter your preferred contact details (e.g. mailing address, etc.)

CCPA Individual Privacy Rights Request Self-Service Form

Authorized Agent Personal Information

Requester Personal Information

Request Details