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Record Access and Correction Request Form

Under the Freedom of Information and Protection of Privacy Act

Request for:

Access to General Records

Access to Your Own Personal Information

Correction to Your Own Personal Information

Title:

Mr.

Ms.

First and Last Name:

Address (Street / Apt. No. / P.O. Box / R.R. No.):

City/Town:

Province:

Postal Code:

Telephone Number (Day):

Telephone Number (Evening):

Email Address:

Detailed description of requested records, personal information or personal information to be corrected (please identify the personal information bank or record containing the person information, if applicable and known):

Preferred method of access to records:

Examine Original

Receive Copy

Signature:

Clear

Date:

Please note:

If requesting your own personal information, you will be required to provide sufficient ID to identify yourself.
If requesting correction of your own personal information, please indicate the desired correction and, if appropriate, attach anysupporting documentation. You will be notified if the correction is not made and you may require that a statement of disagreementbe attached to your personal information.
Each separate request must be accompanied by a $5.00 application fee. To make this payment online, please contact us at 905-494-2120 ext. 29466.

Personal Information contained on this form is collected pursuant to the Freedom of Information and Protection of Privacy Act and will be used for the purpose of responding to your request. Questions about this collection or about the response process in general should be directed to the Freedom of Information office by calling 905-494-2120 ext. 29466 or emailing foi@williamoslerhs.ca.

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