Urgent Yes
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
Part C - Personal Details
Person appearing before the IRB IRB File Number
Client Identification Number
No Yes
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
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IRB/CISR 3000 (07 /15)
Policy and Procedures
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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.)
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.
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.
Aached document
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
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
hp:/ /
IRB/CISR 3000 (07 /15)
Policy and Procedures
Page 2 of 2
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