Protected "B" when completed
Identiﬁcation of Potential Security Risk in IRB Proceedings
The privacy and the protecon of your personal informaon is important to us. The informaon that
you provide will be used for the sole purpose of ensuring the safety and security of Immigraon and
Refugee Board (IRB) personnel, premises and of all persons on these premises. The collecon, use
and disclosure of informaon you provide is protected under the Privacy Act and other applicable
federal legislaon. Under the Privacy Act, you have the right to access your personal informaon and
request changes if the informaon is incorrect. In limited instances, we can share your informaon
without your consent, but will do so only where permied by law. Completed forms will be stored in
Personal Informaon Bank PSU 939.
We may contact you for further informaon if required. Incomplete forms may impact the IRB's
ability to respond to your concerns.
Part A - Contact Information
Your Name (required) Email
Relation to person appearing before the IRB
Part B - Hearing Information
Hearing Date (dd/mm/yy)
In person Teleconference Video Conference
Location (city, province)
Immigraon Division Immigraon Appeal Divsion Refugee Protecon Division Refugee Appeal Division
Part C - Personal Details
Person appearing before the IRB IRB File Number
Client Identiﬁcation Number
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:
Immigraon and Refugee Board of Canada
IRB/CISR 3000 (07 /15)
Policy and Procedures
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