ESDC EMP5616 (2020-04-005) E
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Emploi et
Développement social Canada
Employment and
Social Development Canada
PROTECTED WHEN COMPLETED - B
CANADA SUMMER JOBS - EMPLOYEE CONSENT FORM
The information collected in this form will be used to determine your eligibility for CSJ and for subsequent analysis, research or evaluation purposes.
Completion of this form is mandatory.
ESDC, on behalf of the Government of Canada, is responsible for the evaluation of the Youth Employment and Skills Strategy (YESS) programs in order to
ascertain how beneficial these are to YESS participants. In order to conduct the evaluation activities, your Social Insurance Number will be used to link your
employment and income information from ESDC and other sources (i.e. Canada Revenue Agency for income level). Accurate information is essential for
ESDC to evaluate the program and conduct participant surveys to ensure that the YESS programs meet your needs. ESDC will also use this information for
ESDC YESS program file management and reporting of ESDC's YESS program results.
The collection and use of your information by ESDC is allowed by the Employment and Social Development Act. The information collected and its retention
period are described in the Personal Information Bank ESDC PPU 706.
The information is handled according to the Privacy Act which gives you the right to access and correct your personal information. Instructions for obtaining
your information are available at the following website address: https://www.tbs-sct.gc.ca/hgw-cgf/oversight-surveillance/atip-aiprp/ai/iapih-rpfr-eng.asp.
NAME OF EMPLOYER: PROJECT NUMBER:
EMPLOYEE INFORMATION
I have read the health and safety brochure entitled “Are you in danger?” and agreed to take on the responsibilities of maintaining a safe work
environment for my co-workers and myself.
Yes No
Date of Birth (yyyy-mm-dd)
Surname (as appears on SIN card) Given Name and Initials (as appears on SIN card) Social Insurance Number
Email Address
Permanent Address City
Province Postal Code Telephone Number
Name of Educational Institution Last Attended
Field of Study
Is this my first work experience?
Yes No
In my opinion, is this job related to my field of study?
Yes No
I was registered as a full-time student in the previous academic year.
Yes No
I intend to return to school full-time in the upcoming academic year.
Yes No
If you are not currently a student, how long have you been out of the education system?
Less than 6 months 6 months to 1 year Over 1 year Over 5 years
Highest Level of Education Completed
Elementary Secondary Completed
Secondary Incomplete
Post-secondary Completed
Post-secondary Incomplete University Incomplete (1 or more years)
University Degree
Residency Status
Canadian Citizen Permanent Resident
Refugee under the Immigration and Refugee Protection Act *see definition on page 2
INFORMATION ON EMPLOYMENT EQUITY (MANDATORY)
Gender
Male Female
Other
Decline to answer
Member of a Visible Minority
Yes No Decline to answer
Person with Disability
Yes No Decline to answer
What is the language that you first spoke and still speak?
English French
Other
Indigenous Group
Registered on-reserve Registered off-reserve Non status Metis Inuit N/A
Decline to answer
Recent Immigrant *see definition on page 2
Yes No Decline to answer
