Date:
Time:
Urgent Yes
No
Protected "B" when completed
:
Identification of Potential Security Risk in IRB Proceedings
The privacy and the protecon of your personal informaon is important to us. The informaon that
you provide will be used for the sole purpose of ensuring the safety and security of Immigraon and
Refugee Board (IRB) personnel, premises and of all persons on these premises. The collecon, use
and disclosure of informaon you provide is protected under the Privacy Act and other applicable
federal legislaon. Under the Privacy Act, you have the right to access your personal informaon and
request changes if the informaon is incorrect. In limited instances, we can share your informaon
without your consent, but will do so only where permied by law. Completed forms will be stored in
Personal Informaon Bank PSU 939.
We may contact you for further informaon if required. Incomplete forms may impact the IRB's
ability to respond to your concerns.
Part A - Contact Information
Your Name (required) Email
Phone Number
Relation to person appearing before the IRB
Part B - Hearing Information
Hearing Date (dd/mm/yy)
Scheduled for
In person Teleconference Video Conference
Location (city, province)
Immigraon Division Immigraon Appeal Divsion Refugee Protecon Division Refugee Appeal Division
Tribunal
Part C - Personal Details
Person appearing before the IRB IRB File Number
Alias
Client Identification Number
No Yes
Detained
If released, specify date of release (dd/mm/yy)
Part D - What is the nature of the threat or potential security risk that you are worried about?
Please provide any details regarding specific threats (against whom/nature of the threat).
Describe the threat / security risk:
Immigraon and Refugee Board of Canada
Disponible en
français
hp:/ /www.irb-cisr.gc.ca
IRB/CISR 3000 (07 /15)
Policy and Procedures
Page 1 of 2
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Part E - From whom is the threat originang?
OtherObserver WitnessPerson appearing before the IRB
Part F - Provide any details regarding the individual's criminal history (include any informaon related to
known threats of violence, assault, weapons offenses, gang membership, homicide, organized crime.)
Details
Part G - Provide any details regarding the individual's addicon and mental health concerns
(only if relevant to security concerns). This includes any issue that relates to unpredictability and violence,
which could include some addicon issues, anger management issues or other past behaviours of concern.
Details
Part H - Please idenfy witnesses or observers who may present threatening behavior when appearing
before the IRB for the hearing idenfied.
Name Relaonship
Protected "B" when completed
Part I - You may include any addional relevant informaon and appropriate supporng documents.
Details
Aached document
Details
By clicking on the "Submit" buon below, this form will be saved and aached automacally in an email to the
IRB's Security Services. If you have any other relevant informaon contained in supporng textual or mulmedia
documents, please add them as aachments in the same email.
If the computer you are using does not have a default e-mail client and does not provide you with other opons
to use your on line email applicaon instead, please click on the "Save" buon below to save this form locally
and then attach it to your email application with any other relevant document(s) and send it to
IRB.Secur.CISR@irb-cisr.c.ca.
You can also print out this form and fax it to us at the following number: (613) 943-2045.
Immigraon and Refugee Board of Canada
Disponible en
français
hp:/ /www.irb-cisr.gc.ca
IRB/CISR 3000 (07 /15)
Policy and Procedures
Page 2 of 2
Save As
Submit
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