Sample Voluntary Self Disclosure Form Template

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Sample Voluntary Self Disclosure Form Template Powered By Docstoc
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Freedom of Information & Protection of Privacy

VOLUNTARY SELF-DISCLOSURE FORM
To: Program/Course:
The consent of an individual to a public body disclosing any of the individual’s personal information under Section 33(b) of the Act must: (a) be in writing, and (b) specify to whom the personal information may be disclosed and how the personal information may be used.

Applicant (Person/Organization Requesting Information):
Name: Organization: Phone: Title: Address:

Information Requested: Purpose: Rationale: a. b.

PROGRAM TRAINING RECORDS (e.g., marks, attendance, start and end dates, program and course information.) a. [ ] Condition of Sponsorship b. [ ] Reference Checks (Job or Employee Search)

c.

a. Condition of Sponsorship: The College is often contacted by persons or organizations (e.g., parent, sports organization) requesting training record information about the student sponsored, as condition of being sponsored. The College may not respond to these requests unless the sponsor is another government agency, or unless the student has submitted a Voluntary Self-Disclosure Form to the College. b. Reference Checks: The College is often contacted by potential future employers requesting training record information on job applicants, or as part of a search for new employees. The College may not respond to these requests unless the student has specifically named the College as a referee on the job application, or unless the student has submitted a Voluntary Self-Disclosure Form to the College.

Voluntary Self-Disclosure Statement (Individual’s consent to release information):
By signing this voluntary self-disclosure form I hereby give the College permission to release the information noted hereon, in writing or by telephone, for the purposes indicated, as follows (please write your initials in the applicable box(es)): a. b. c. d. e. [ [ [ [ ] ] ] ] to the above-named applicant; or to a company as a result of my job application thereto; or to a company in response to a general request to the College for possible job candidates. all of the above. Re: Item c. -- I give the College permission to release my phone number.

[_ __ _]

Signature: Address:

Date: Phone:


				
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