Fillable 2018 Privacy Complaint Form %28fillable%29 - 2018_privacy complaint form

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2018 Privacy Complaint Form %28fillable%29 - 2018_privacy complaint form

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Freedom of Information and Protection of Privacy: Privacy
Complaint Form
Part 1: About the Complainant
Mr. Mrs. Ms. Miss Dr. N/A
Last Name: First Name:
Address:
City: Postal Code: Province:
Email Address: Phone:
Part 2: Details of the Complaint
Please provide a detailed description of your privacy complaint covering the
what, when, who, how, where
and
why
of the incident. If additional space is required, please attached additional pages.
Name of department the complaint relates to:
Please indicate if you have reason to believe that one or more of the following has occurred:
The department has inappropriately collected my personal information
The department has inappropriately disclosed my personal information
The department has inappropriately used my personal information
The department has inappropriately disposed of my personal information
Other:
Description of complaint:
Freedom of Information and Protection of Privacy: Privacy Complaint Form
Page2|2
Part 3: Resolution of Complaint
Please describe how your privacy complaint could be resolved:
Part 4: About the Process
Submit completed complaint forms to:
University Secretariat
University Centre, 4
th
Floor
50 Stone Road East
Guelph, Ontario
N1G2W1
The University Secretariat will investigate your complaint to ensure the immediate requirements of
containment and notification have been addressed, to review the circumstances surrounding the breach,
and to review the adequacy of existing policies, procedures, and training in protecting personal information.
Part 5: Complainant’s Consent
Consent to disclose your name to the department the complaint is related to:
I consent to my name being disclosed to the department in order to investigate this complaint
I do not consent to my name being disclosed to the department
Consent to provide a copy of documentation to the department the complaint is related to:
I consent to a copy of this form and all attachments being provided to the department
I do not consent to a copy of this form and all attachments being provided to the department
Part 6: Complainant’s Signature
Signature: Day: Month: Year:
Personal information on this form is collected under the authority of the University of Guelph Act, 1964 and in
accordance with Ontario’s Freedom of Information and Protection of Privacy Act. This information will be used
for the purpose of responding to your complaint. Questions about this collection should be directed to the
University’s privacy officer, University Secretariat, 519-824-4120 x.56571 or by email to fippa@uoguelph.ca.
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2018 Privacy Complaint Form %28fillable%29 - 2018_privacy complaint form

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Completed 17 March 2020

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