Personal Information Protection and Electronic 
Documents Act (PIPEDA) 
Complaint Form

SECTION 1: Complainant / Representative Information 

If you are the complainant, you should complete the section “Complainant Information.”

If you represent the complainant, you should complete the sections “Complainant Information” and “Representative Information,” as well as the authorization form available on our website.

1. Are you making this complaint on your own behalf? *    Yes   No 
If ‘No’, please make sure that you send us a written authorization from the person you are representing.

Complainant Information
First name *
     	Last name *
     	Email address
     	
Mailing address *
     	City *
     	
Province *
     	Postal code *
     	Country (if outside Canada)
     	
Daytime Telephone number *
     	Alternative Telephone number
     		
Please enter the Daytime Telephone Number as the best number to contact you from Monday to Friday, 8:30am to 4:30pm ET.	

The OPC is committed to ensuring that clients with disabilities have equal access to, and can benefit from, all our public-facing services. If you are requesting accommodation for a disability in our complaint investigation process, your request should be made in writing, unless you are unable to do so.

•	When requesting accommodation for a disability in writing, please describe the nature of the accommodation requested and the rationale for the request in the text box below.
•	If providing the information in writing would limit your ability to make such a request, please contact our Information Centre. An Information Officer will assist you in making your request directly or refer you to the appropriate person. 

 Only use this space if you are requesting accommodation for a disability. Otherwise, please leave this space blank.
     

Representative Information (if applicable)
First name *
     	Last name *
     	Email address
     	
Mailing address *
     	City *
     	
Province *
     	Postal code *
     	Country (if outside Canada)
     	
Daytime Telephone number *
     	Alternative Telephone number
     		
Please enter the Daytime Telephone Number as the best number to contact you from Monday to Friday, 8:30am to 4:30pm ET.	
* Required fields 

SECTION 2: Details of Complaint 
Please provide information about your complaint below.
You should also describe any efforts you made to resolve the issue with the organization concerned.

2. Which organization is your complaint against? * (Please identify by specific name and location. Provide legal name of organization, if known.)
     

3. Are you submitting the complaint as a customer or as an employee of the organization? *
 Customer                Employee 

4. Summarize your complaint. * (Please describe the events or circumstances that led to your complaint. Include details such as the names or positions of people involved in the incident, the locations where the incident occurred, and any other factors you consider relevant. If the organization gave you a reference number in relation to this issue, please include it as well.)

     

5. Have you attempted to resolve the matter with the organization?
 Yes      No

If ‘Yes’, please outline your efforts and describe the result, if any. If ‘No’, please specify the reason why not.

     

6. Have you complained about this incident to another body or organization?
 Yes      No 

If ‘Yes’, please provide details. (Indicate the name of the body, and include relevant details such as dates and a reference number.)

     

7. How can the Office of the Privacy Commissioner of Canada help address your concerns? * (Please describe any steps or remedies that would resolve your issue.)

     

* Required fields

SECTION 3: Documentation 
If you have documents relating to your complaint, please attach them to your complaint:
•	Any correspondence between you and the organization on this matter.
•	Any documentation that indicates that you are authorized to act for another person (authorization form).
•	Other relevant documentation.

 Documents will be sent under separate cover to the address below
 Documents attached

Please list the file names of the attached documents.	
1.	     	
2.	     	
3.	     	
4.	     	
5.	     	
6.	     	
7.	     	

SECTION 4: Certification
By signing this form, you certify that the information you provided on this form, to the best of your knowledge, is true and complete.
     
______________________________
                  First and last names (print)

							     
______________________________	______________________
                               Signature					Date (dd/mm/yyyy)

Send Complaint Form to:

Office of the Privacy Commissioner of Canada
30 Victoria Street
Gatineau, Quebec
K1A 1H3	Inquiries:
Toll-free: 1-800-282-1376
Phone: (819) 994-5444
TTY: (819) 994-6591

The personal information you provide on this form is protected under the provisions of the Access to Information Act and the Privacy Act. Please note that your name and the details of your complaint will be shared with the organization that is the subject of the complaint.