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AMIANISM — THE SIGNAL — PDF PAGE 30
AMIANISM — The Signal / PDF PAGE 30 OF 36

The Four Rights Request

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27
The Four Rights Request
Copy, adapt, and submit this request to the institution responsible for
a consequential automated judgment. Preserve the version you sent
and every response.
Subject: Request for Notice, Reasons, Human Appeal, and Repair
On [DATE], [INSTITUTION] made or materially influenced the
following consequential decision affecting me: [DESCRIBE THE
DECISION].
1. NOTICE
Did an algorithm, automated score, ranking system, predictive
model, generative system, or automated workflow materially
influence this decision? Please identify its role, the responsible
institution, the decision date, and a durable case number.
2. REASONS
What data, rules, objectives, material factors, and source records
influenced the result? Please provide a human-understandable
explanation and identify any information that I may inspect or
correct.
3. HUMAN APPEAL
Who is the accountable human reviewer with authority to reconsider
or reverse this decision? Please provide the procedure, deadline, and
expected response time.
4. REPAIR
If the decision or its data is wrong, what process corrects the source
record, notifies downstream systems, reverses the decision, and
restores lost access, pay, benefits, status, opportunity, reach,
reputation, or standing?
Please preserve all records related to this request and respond by
[DATE OR APPLICABLE DEADLINE].
[NAME]
[CONTACT INFORMATION]
[CASE OR ACCOUNT REFERENCE]
Before sharing any case publicly, remove private data that is not
necessary to establish what happened.
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