Class Member Consent Form - Testimonial from Participating in the Restorative Engagement Program

The Sexual Misconduct Support and Resource Centre’s Restorative Engagement (RE) program is looking for testimonials about class member experiences with the RE program. You are not asked to share your experience of sexual misconduct but rather what you thought of your time in the RE program and its impacts.

All testimonials collected from class members can only be received in a written format and will be deidentified to protect your personal information before it is included in any external or internal communications about RE. No personal information will be shared.

However, there is a possibility that you could be identified by the content of the testimonial as these may contain details that pertain to various aspects of your personal experience within the RE program and your opinions on the matter. Please ensure that you are satisfied with how much or how little you decide to share. Additionally, you have the right to withdraw your consent at any time before publication.

Important Note: Once the material has been published, while the Restorative Engagement program will stop using your testimonial, it may not be possible to completely remove all digital traces of it.

Privacy Notice Statement

As a Restorative Engagement program participant, the testimonial you provide is considered personal information which DND/CAF protects in accordance with the Privacy Act. Once you submit your testimonial to the Restorative Engagement program, it will be de-identified before it is used internally by the SMSRC for the purpose(s) you selected above. Your testimonial will not be used or disclosed for any other purpose without your consent.

For the SMSRC to use your testimonial, we are required to obtain your consent within these limits. Thank you for considering providing your testimonial.

This collection of personal information is described in Personal Information Bank DND PPU 882 – Restorative Engagement Program published in DND’s InfoSource page.

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, contact DND/CAF’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

You also have the right to file a complaint with the Privacy Commissioner of Canada regarding out handling of your personal information.

Class member name (first and last name)

Enter date of birth:

Year

Month

Day

Consent For Other Potential Use(s) of Testimonial

You can choose how your testimonial is used by the Restorative Engagement program.

Please indicate below what option(s) you consent for use of your testimonial:

Communication products (in print or online, such as but not limited to articles, social media content, information sessions, etc.)

Internal uses within the Restorative Engagement program (i.e. for research, reports and internal evaluation and to inform the work of the Department of National Defence (DND) / Canadian Armed Forces (CAF))

External uses for the institution (i.e. to develop training materials or resources for DND/CAF members, to inform policy or procedural changes within the organization, for the final report of the program, to create awareness campaigns or educational initiatives, and/or to provide insights for leadership development programs)

Statement of Understanding

I understand that the Restorative Engagement program may or may not use my testimonial. When publishing any class member testimonials, the text of any material may be edited for style, grammar, and consistency before publication.

I understand that the Restorative Engagement program will remove any identifying information and take all reasonable steps to protect my privacy and create a de-identified version of my testimonial, but that complete anonymity cannot be guaranteed.

I understand that the use of the testimonial does not require prior approval by me.

I understand that I can withdraw my consent at any time before publication, but once the material has been published, while the Restorative Engagement program will stop using my testimonial, it may not be possible to completely remove all digital traces of it.

I understand that to withdraw my consent to release my testimonial by the Restorative Engagement program, I must notify the program in one of the following ways: • In writing to the assigned restorative practitioners via email or other correspondence. This is the preferred method. If email addresses are unknown, email can be sent to the regional positional mailbox listed at the end of the form. • Verbally to the restorative practitioner(s). They will document the date, time and new direction received.

By submitting this form, I indicate that:

I have had an opportunity to discuss the use of testimonials in the Restorative Engagement program with a restorative practitioner.

I have carefully read this form and understand the conditions to use, and

I consent to the use my testimonial as indicated above.

Regional Mailbox List:

In the event you cannot locate the email addresses for your assigned restorative practitioners, you may email your correspondence to the Regional Positional Mailbox for your region at the email address listed below and it will be forwarded to the correct person.

Region and their assigned Positional Mailbox

East (NL, NB, NS, PEI, QC, NCR-French and International): REeast-DRest@forces.gc.ca

Central (ON and NCR English): REcentral-DRcentrale@forces.gc.ca

West (BC, YK, MB, SK, AB, NT, NU): REwest-DRouest@forces.gc.ca