Restorative Engagement Intake Form
Government of Canada / Gouvernement du Canada

Language selection

Françaisfr

Restorative Engagement Intake Form

This form is designed to verify and update your contact details, as well as to collect your decision regarding participation in the Restorative Engagement program.

Indicate your first and last name. The middle name is optional.
Enter your phone number. For example: 111-222-3333
Can the Restorative Engagement program leave you a voicemail?
Enter an email address. For example: name@example.com
What is your preferred language for communication?
We offer our services in both official languages, French and English

What is your address?

Include your civic number and street name, apartment or suite, and other address details

The personal information identified above will be shared for the following purposes:

  1. Closing your file if requested.
  2. Assigning a Restorative Practitioner to your file and scheduling an initial call if you choose to move forward.
  3. Following up on any questions regarding your intake form using your identified preferred method of contact.

Privacy Notice Statement

 

The Restorative Engagement Program (herein referred to as the Program) of the Sexual Misconduct Support and Resource Centre (SMSRC) is committed to protecting the privacy rights of individuals and safeguarding the personal information under its control. "Personal information" is defined as information about an identifiable individual that is recorded in any form; refer to section 3 of the Privacy Act for further details and examples of personal information. Your responses on this form are considered personal information.

 

The personal information on this form is collected under the authority of s. 4 of the National Defence Act and will be used by the Program for the following purposes:

 

  1. Receive and record your continued interest in participating in the Program.

  2. Contact you to provide more information on the Program.

  3. Consider any existing accommodations, barriers, or concerns to best support your participation in the Program; and

  4. Program evaluation and aggregate statistics.

 

Following the submission of this form, further information on the program will be provided to you so you understand your options regarding Program participation. Once you are fully aware of your options, a Consent Form will be provided to you for review and signature. Please note that the Program will not use the information you submit on this form, including your contact information, for any purposes other than those described in this privacy notice statement without first obtaining your explicit consent, except when otherwise required by law, which includes the circumstances listed under ss. 8(2) of the Privacy Act.

 

Personal information collected, as well as its use, disclosure, and retention, is typically described in a Personal Information Bank published on DND’s Info Source page. At this time, the relevant Personal Information Bank, which will be called Restorative Engagement Program (DND PPU 882), is under development and is not yet found on the DND Info Source page. However, note that personal information collected by the Program will be retained for five years after the last administrative action and then destroyed.

 

Under the Privacy Act, you have the right to access your personal information and request corrections to your personal information. Should you wish to exercise your rights under the Privacy Act, or have any questions about this privacy notice statement, contact DND’s Directorate of Access to Information and Privacy (DAIP) by submitting a Personal Information Request Form online, or send a written request to:

 

Directorate of Access to Information and Privacy (DAIP)

Department of National Defence

60 Moodie Drive

Ottawa, Ontario K1A 0K2

 

Should you wish to lodge a complaint with respect to the handling of your personal information, you may do so by contacting the Office of the Privacy Commissioner of Canada.

Date modified: 2024-01-17