The following questions are based on the CANADIAN CHARTER OF RIGHTS AND FREEDOMS, CANADIAN BILL OF

RIGHTS and are necessary in order that the individual or representative thereof (herein after called “the one”), delivering this

questionnaire, may make reasonable determination concerning divulgence of information to your agency and to endure security of

rights, personally or corporately, joined and/or severally.

1. Name of public servant:________________________________________________________________________________

2. Name of department of government, bureau or agency by which public servant is employed:

___________________________________________________ Supervisor:________________________________________

3. Its mailing address: City________________________________ Province:_______________ PC_____________

4. Will public servant uphold the CANADIAN CHARTER OF RIGHTS AND FREEDOMS as it pertains to the one issuing the

questionnaire? Yes:____________ No:___________

5. Will public servant issue official identification at every interview? Yes:__________ No:__________

6. What was / will be the nature of proof? ID#_______________________ Badge#:_____________

7. Will public servant furnish a copy of the law or regulation which authorizes any investigation as it pertains to the one issuing this

questionnaire?: Yes:_______________ No:_____________

8. Will the public servant read aloud, prior to the asking the one questions, the law authorizing the questions to be asked?

Yes:________________ No:_______________

9. Are the answers to be provided by the one voluntary? ____________________ or mandatory? ______________________

10. Are the questions to be asked based on a specific law or regulation? ________________________________ or are they being

used in a discovery process? _____________________________________________

11. What other uses may be made of this information the public servant is seeking from the one?

___________________________________________________________________________________________________

12. What other agencies or the like may have access to this information?________________________________________________

_____________________________________________________________________________________________________

13. What will be the effect upon the one if the one should choose to not answer questions asked by the public servant?

___________________________________________________________________________________________________

___________________________________________________________________________________________________

14. Name of the person in the government requesting that an investigation be made upon the one?

__________________________________________________________________________________________________

15. Is this investigation general___________________________________or is it special?__________________________________

of geography, type of business, income, etc. By “special”, it is meant any investigation of an individual nature in which

others are not involved.

16. Have you consulted, questioned, interviewed or received information from a third party, relative to this investigation of the one?

Yes:_____________________ No:__________________

17. If yes, the identity of such third parties: __________________________________________________________

18. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the information which

you seek from or pertaining to the one?: Yes:_________________ No:_____________________

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19. If so, (18) indicate which: ____________________________________________________________________

20. Is there a file of records, information or correspondence relating to the one, being maintained by this agency?

Yes:______________________ No:__________________

21. Is this agency using any information pertaining to the one which was supplied by another agency of government source?

Yes: ____________________ No: ____________________ if Yes, which?: ______________________________________

22. Will the public servant guarantee that the information in these file(s) will not be used by any other department other than by

whom he/she is employed? Yes: _________________ No:_________________

23. Will the public servant fully disclose to the one and fully disclose all files of records mentioned in #20?

Yes:__________________ No: ________________

If a request of information pertaining to the individual or representative thereof issuing this questionnaire is received by yourself or

your agency, from any third party, you are to advise in writing the individual issuing this questionnaire of said request for

information, before releasing such information. Failure to do so may subject you to civil or criminal action as provided.

AFFIRMATION BY PUBLIC SERVANT

I hereby certify the answers I have given to the forgoing questions are complete and correct in every particular.

Signed:____________________________________ Print:____________________________________________

Date:_____________________________________

Witness: __________________________________ Print: _____________________________________________

Witness: __________________________________ Print: _____________________________________________

DO NOT USE THIS AREA... IN HOUSE USE

FOR INTERVIEW PURPOSES ONLY

EVIDENCE OF REFUSAL TO COMPLETE AND ENDORSE AS DEMANDED

of government official

Dated: _____________________________________

First Witness:________________________________

Second Witness:______________________________

FOR PUBLIC SERVANT USE ONLY

IF PUBLIC SERVANT REFUSES TO COMPLETE AND ENDORSE AS DEMANDED, PLEASE INDICATE SO

Dated:__________________________________

________________________________________

please print refused and have witnessed

Witness _________________________________

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