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The Four Rights Request

Create a request for notice, reasons, accountable human appeal, and repair. The form runs locally in your browser and does not transmit your entries to this site.

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SectorInstitution or organizationYour name or chosen identifierReference or case numberResponse deadlinePreferred response method

Brief description of the decision

Editable request

Subject: Request for Notice, Reasons, Human Appeal, and Repair

I am requesting information and review concerning a decision, classification, ranking, restriction, or outcome that materially affected me.

1. NOTICE
Please confirm whether an automated, algorithmic, statistical, AI-assisted, scoring, ranking, profiling, recommendation, or generated-summary system materially influenced the outcome. Identify the system role, responsible institution, decision date, and case reference.

2. REASONS
Please provide an understandable explanation of the principal factors that shaped the result, including relevant source records, policies, criteria, objectives, material inferences, and known uncertainty.

3. HUMAN APPEAL
Please provide access to an accountable human reviewer with sufficient time, information, independence, and authority to reconsider and, where appropriate, reverse the outcome.

4. REPAIR
If the decision or its data is wrong or materially incomplete, please explain the process to correct the source record, update downstream systems, reverse the outcome where justified, and restore what was wrongly lost.

Please identify the review procedure, deadline, expected response time, and office or person responsible for the final decision. I am preserving this request and the response as part of my record.

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