Privacy and Confidentiality Policy Implementation Procedures

Multiple Sclerosis Society of Canada Privacy and Confidentiality Policy Implementation Procedures

September 2003
Revised September 2004 Revised January 2009

Developed by
Multiple Sclerosis Society of Canada Privacy Officers
175 Bloor St. E., Suite 700
Toronto ON M4W 3R8

Telephone: 416 922-6065

Fax: 416 922-7538

E-mail: info@mssociety.ca

Web site: www.mssociety.ca

Table of Contents

IMPLEMENTATION PROCEDURES ...................................................................4

DEFINITIONS .......................................................................................................5

PRIVACY PRINCIPLES AND APPLICATION .....................................................6

PRINCIPLE 1 – ACCOUNTABILITY .................................................................................... 6

PRINCIPLE 2 – IDENTIFYING PURPOSES ......................................................................... 7

PRINCIPLE 3 – CONSENT ................................................................................................ 8

PRINCIPLE 4 – LIMITING COLLECTION ............................................................................ 9

PRINCIPLE 5 – LIMITING USE, DISCLOSURE AND RETENTION ....................................... 9

PRINCIPLE 6 – ACCURACY ............................................................................................ 13

PRINCIPLE 7 – SAFEGUARDS........................................................................................ 13

PRINCIPLE 8 – OPENNESS ............................................................................................ 15

PRINCIPLE 9 – INDIVIDUAL ACCESS.............................................................................. 16

PRINCIPLE 10 – CHALLENGING COMPLIANCE .............................................................. 17

APPENDIX I .......................................................................................................18

OPAL INFORMATION SYSTEM DATA SHARING PRINCIPLES.......................................... 18

APPENDIX II ......................................................................................................19

PRIVACY FORMS AND STATEMENTS ............................................................................. 19

Release of Information Form................................................................................ 20

Volunteer and Staff Privacy and Confidentiality Agreement ........................... 21

Image/Text Identification Release Form............................................................. 22

General statement for all forms............................................................................ 23

Statements for membership forms ...................................................................... 23

Statement for fax cover sheets ............................................................................ 24

Statements for client forms ................................................................................... 24

for volunteer forms .............................................................................. 24

Statements for fundraising forms......................................................................... 25

Privacy and Confidentiality Policy Implementation Procedures

The following procedures will assist Multiple Sclerosis Society of Canada volunteers and staff in complying with the Privacy and Confidentiality Policy (approved by the National Board of Directors, May 4, 2002 – the “Privacy Policy”).

This policy is based on the 10 principles of the federal Personal Information Protection and Electronics Documents Act (PIPEDA) that guide how organizations collect use, disclose and retain personal information. In addition, the Multiple Sclerosis Society of Canada has developed its own policies and procedures about the collection, use and disclosure of information following the privacy principles set out in PIPEDA and/or provincial/territorial legislation.

The examples provided help illustrate the privacy principles on which this policy is based. However, the guidelines cannot cover all the needs and circumstances at all times. Questions about specific circumstances that do not appear to be covered by the Privacy Policy and the Implementation Guidelines should be directed by chapters/units to their division privacy officer. Divisions that need clarification or assistance should contact the national privacy officer.

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Definitions

Personal Information – Under PIPEDA, personal information is defined as information about an identifiable individual. Personal information includes an individual’s name, home address and home phone number. It does not include the name, title or business address or business telephone number of an employee of an organization. Personal information is to be understood in the broadest sense if it is information that relates to an identifiable individual. For example, the information about an individual’s donations to the MS Society is personal information.

As used in this Implementation Procedures, the term Personal Information includes Personal Health Information.

Multiple Sclerosis Society of Canada (MS Society) – The MS Society is defined as including all levels of the organization, the national office, divisions, chapters and units.

Privacy Principles and Application

Principle 1 – Accountability

This principle requires MS Society volunteers and staff at all levels of the organization to be responsible for the Personal Information we have under our control. It also requires the MS Society to designate individuals to be responsible for ensuring the MS Society complies with all aspects of its Privacy Policy and PIPEDA principles and that this has been done and is set out in the Privacy Policy.

1.1  In addition, other individuals within the MS Society may be delegated to act on behalf of the designated individual(s) and be responsible for the day-to-day collection and processing of Personal Information.

1.2  While the designated individual(s) are accountable for compliance, they are not authorized to have access to member and/or client Personal Health Information unless they are also Client Services volunteers or staff.

1.3  The MS Society, upon request, will disclose to members of the MS Society, clients, donors, volunteers and the general public the identity of the individual(s) designated by the MS Society to oversee privacy and confidentiality.

1.4  When the MS Society transfers Personal Information in its possession to a third party, the information must be protected through contractual means to ensure a comparable level of protection while the information is being used by the third party.

Other Applications to MS Society programs and services:

  •  The privacy statement on the MS Society web site must contain information about the MS Society’s privacy policy and an individual to contact for more information or to make a complaint.

Principle 2 – Identifying Purposes

The Privacy Policy requires the MS Society to clearly identify the purposes for which it is collecting Personal Information. This must be done at or before the time information is collected.

2.1 The collection of information can be done orally (either in person or over the telephone) or in writing. For example, an individual could contact an MS Society chapter by telephone asking to become a member. The volunteer or staff member would record the information using either the appropriate Opal Information System or another form, and at the same time verify the accuracy of the information, confirm the individual’s consent in providing the information and the MS Society’s use of that information. In the case of a member, for example, the purposes are to allow the MS Society to send the individual newsletters, information about educational sessions, conferences and annual general meetings and to collect anonymous information for statistical purposes only.

2.2  An individual can be asked if he/she wishes to disclose a diagnosis of MS for statistical purposes or to receive MS Society newsletters free-of-charge (if this is the case for the division or chapter/unit). MS Society mailing lists (such as that drawn from the Opal IS or any other mailing list) should not contain any identifying information which would indicate a person has MS since this is considered Personal Health Information. In addition, only Client Services volunteers and staff or their authorized designates should have access to information about individuals’ Personal Health Information. (Authorized designates are other volunteers or staff such as those involved in Finance. See the section “Members and Clients” in Principle 5 – Limiting Use, Disclosure and Retention.)

2.3  The MS Society cannot use Personal Information that has already been collected for designated purposes for a new purpose without the consent of the individual(s) involved.

Principle 3 – Consent

The MS Society must obtain consent for the collection, use and disclosure of personal information in whatever form. This should be done at the time of collection, and the individual should be informed at that time of the necessity for collecting Personal Information.

3.1  An individual’s consent may be either express or implied, depending upon the circumstances and the sensitivity of the information involved. Health information, details of an individual’s donation history or personal/ family income are more sensitive than simple Personal Information such as name and home address and home telephone number in most instances.

3.2  Express consent is required for the MS Society to disclose health information about a member or client to an individual or organization external to the MS Society, (e.g., one of the MS Clinics affiliated with the MS Society or a company that supplies assistive devices). The individual should sign the MS Society Release of Information Form before the information is disclosed, if at all possible. (See Appendix II) If it is not feasible for the form to be signed in advance, verbal permission must be obtained and documented. A follow-up letter should be then sent advising the individual that he/she has given verbal permission to release health information and to whom it has been disclosed. The individual should be requested to sign the Release of Information Form and return it to the originating office. Consent can also be given by an authorized representative (such as a legal guardian or a person having power of attorney provided that the necessary legal documentation is provided to the MS Society confirming the individual’s appointment as legal guardian or the holder of the power of attorney.)

3.3  Express consent is required for MS Society volunteers or staff to share an individual’s health information (including the diagnosis of MS) with other people who have MS either individually or at MS Society meetings, educational sessions and/or self-help groups and with news media. Consent can be in writing or verbal. If consent is given verbally, the express consent should be documented in writing by the MS Society volunteer or staff obtaining the consent.

3.4  Implied consent is considered to be sufficient for fundraising purposes to allow the trade of limited Personal Information (name and home or business address only) about a donor to another charitable organization if the individual has been informed that his/her Personal Information might be used in this manner and he/she has been given an opportunity in a clear and meaningful way to opt out.

3.5  The MS Society will not, as a condition of the supply of a service or product, require an individual to consent to the collection, use, or disclosure of information beyond that which is required to carry out the specified purposes.

3.6  An individual may withdraw consent at any time, subject to legal or contractual restrictions and reasonable notice to the individual’s Personal Information.

Principle 4 – Limiting Collection

4.1  The MS Society will not collect Personal Information indiscriminately. Both the amount and the type of information collected will be limited to that which is necessary to fulfill the purposes identified.

4.2  The MS Society recognizes its responsibility to collect Personal Information by fair and lawful means and will not collect information by misleading or deceiving individuals about the purpose for which information is being collected.

Principle 5 – Limiting Use, Disclosure and Retention

The MS Society will ensure that the Personal Information collected will only be used or disclosed for the purposes for which it was collected. If another use or disclosure is identified, the individual must be contacted and asked to consent to this new use or disclosure.

5.1 If the MS Society wishes to use Personal Information for a new purpose, it will seek consent describing this new purpose and document that consent has been given.

5.2  MS Society has developed procedures with respect to the retention of various types of Personal Information under its direct control. The record retention procedures include minimum and maximum retention periods. The MS Society recognizes it may be subject to various legislative requirements with respect to retention periods. (See the Record Retention Procedures.)

5.3  Specific to Canada Customs and Revenue Agency regulations, the MS Society is obligated to keep tax records and other related accounts for specific periods of time as per the Record Retention Procedures.

5.4  Personal Information that is no longer required to fulfill the identified purposes will be destroyed, erased, or made anonymous as per the Record Retention Procedures.

Specific applications of the privacy principles as implemented with respect to MS Society programs and services:

Fundraising

  • There must be a clear statement on direct mail letters and/or coupons informing donors their names may be traded to other charitable organizations and providing an easy way for donors to opt out of having their names traded.
  • All web-based and printed registration and pledge forms for the MS Society fund raising events should seek express permission from participants and donors to contact them via e-mail in the future. (See Appendix II for appropriate wording.)
  • All registration and donation forms shall include a short privacy statement and a statement directing people to the MS Society full privacy statement on the MS Society web site and provide a toll-free number for people to call for more information. (See Appendix II for appropriate wording.)

  •  The MS Society should not collect more information than is needed. For example, if we collect information about food or other allergies from event participants but have no method of ensuring that they will not come in contact with those allergens at a fund raising event, that collected information is not required or necessary. Collecting the information may also raise expectations that the MS Society is legally liable for keeping them away or protecting them from those specific allergens.

  • Once an individual advises the MS Society that he/she does not want to have his/her name traded to other charitable organizations, the name of that individual will be flagged or identifed in the MS Society Opal IS and/or other data bases as a “do not trade” name and will retain the “do not trade” status unless and until that individual later consents to have his/her name and address traded to another charity by signifying in writing to the MS Society. Even if a donor sends in donation in response to a direct mailing and fails to modify instructions given prevously not to trade his/her name with other charitable organizations, the MS Society will keep that individual on the “do not trade” list.

Members and Clients

The MS Society National Board of Directors has directed that MS Society membership and client information is to be held in confidence and has stipulated the information cannot be released to other organizations or to individuals under any circumstances except as required by law.

As an additional safeguard, the National Board of Directors in June 2001 approved the Opal Data Sharing Principles, which limits who within the MS Society has access to personal information about people with MS. In this case, Personal Health Information includes whether a person has MS as well as more detailed information. Access to such information is restricted to Client Services Programs staff and volunteers, on a “need to know” basis. In addition, authorized Client Services volunteers and staff may permit non-Client Services volunteers and staff to have access to personal health information on a restricted “need-to-know” basis so they can carry out their jobs (e.g., Finance volunteers or staff can be authorized to have access to Personal Health Information so they can carry out their jobs of paying invoices).

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Members

  • Membership application forms whether printed in brochures, as stand-alone forms or on the Opal Information System or on the MS Society web site must contain a statement advising applicants that the MS Society protects their privacy and confidentiality. The statement should also inform individuals the information collected is used to compile mailing lists for newsletters, notices about programs and annual general meetings and for anonymous statistical analysis. The notice should also state that Personal Information is never released to any individual or organization external to the MS Society. (See Appendix II for appropriate wording.)

  • In addition, membership application forms must contain a statement informing members that membership information may be provided to other members from time to time for the purpose of soliciting proxy votes or signatures for nomination forms for MS Society annual general meetings. (See Appendix II for appropriate wording.)

  • Members who are granted access to the membership list by the appropriate board of directors will be required to sign a statement declaring that the information contained in the membership list will be used only for the soliciting of proxy votes or signatures for nomination forms.

Clients

  • Forms used to record information about clients whether printed in brochures, as stand-alone forms or on the Opal Information System or on the MS Society web site must contain a statement advising individuals that the MS Society protects their privacy. The statement should also inform individuals that the information collected is used to provide benefits to the client such as providing equipment or special assistance funding, developing programs and services, notices about programs and for anonymous statistical analysis. (See Appendix II for appropriate wording.)
  • In all cases, Client Services volunteers and staff or their authorized designates should obtain consent to collect this information from the individual, preferably in writing on the form used to record the information obtained from the client.
  • The Client Services volunteer and staff should ask the individual to verify the accuracy of the information collected and if possible to sign the form.

Release of information about a person with MS and/or family member must be obtained prior to the release of that information. Information can be released only to authorized individuals within the MS Society on a “need to know” basis or to external individuals, organizations or companies authorized to have this information to fulfill a service or program. (See Appendix II for the Release of Information Form.)

Principle 6 – Accuracy

6.1  The extent to which Personal Information will be accurate, complete, and up-to-date will depend upon the use of the information, taking into account the interests of the individual. Information will be sufficiently accurate, complete, and up-to-date to minimize the possibility that inappropriate information may be used to make a decision about the individual.

6.2  Personal Information that is used on an ongoing basis, including information that is disclosed to third parties, should be accurate and up-to-date.

6.3  The MS Society is not obligated to routinely update Personal Information, unless such a process is necessary to fulfill the purposes for which the information was collected.

Principle 7 – Safeguards

Multiple Sclerosis Society of Canada volunteers and staff at all levels will put in place security safeguards appropriate to the sensitivity of the information.

7.1

The security safeguards are intended to protect Personal Information against loss or theft, as well as unauthorized access, disclosure, copying, use, or modification. The safeguards are intended to
protect Personal Information regardless of the format in which it is held.

7.2  The nature of the safeguards will vary depending on the sensitivity of the information that has been collected, the amount, distribution, and format of the information, and the method of storage. A higher level of protection will be employed to safeguard more sensitive information .

7.3  The methods of protection will include:

  • (a) physical measures, for example, locked filing cabinets and restricted access to offices;
  • (b) organizational measures, for example, security clearances and limiting access on a "need-to-know" basis; and
  • (c) technological measures, for example, the use of passwords and encryption on laptops.

7.4  The MS Society will make its volunteers and staff aware of the importance of maintaining the confidentiality of Personal Information through various training programs.

7.5  All staff will be required to read the Privacy Policy and sign the Volunteer and Staff Privacy and Confidentiality Agreement. (See Appendix II)

7.6  Volunteers who have access to Personal Information will be required to read the Privacy Policy and sign the Volunteer and Staff Privacy and Confidentiality Agreement.

7.7  Casual volunteers (e.g., event volunteers who do not have access to Personal Information) are not required to read the Policy or sign the Agreement.

7.8  If an individual refuses to sign the Volunteer and Staff Privacy and Confidentiality Agreement after having been informed of the policy, the individual will no longer be allowed access to Personal Information. This refusal must be documented and the individual advised in writing of this action.

7.9  Care must be used in the disposal or destruction of Personal Information, both in paper format and electronic to prevent unauthorized parties from gaining access to the information. Typically this information should be shredded if in paper format or deleted or made anonymous if in electronic format.

7.10  Where a computer or laptop is to be disposed of by the MS Society and that computer or laptop has contained Personal Information, the storage device must be reformatted or destroyed as per the Record Retention Procedures.

7.11  Devices such as computer disks (CD) or USB sticks containing Personal Information must be kept under the control of the individual using them at all times. It is recommended that CD and USB sticks containing Personal Information be password protected. Staff and volunteers who need to password protect such devices should contact the MS Society Information Technology Department for up-to-date information about how to carry out this procedure.

7.12  The MS Society will endeavour to provide appropriate education and disseminate information about its Privacy Policy for all staff and volunteers who have access to Personal Information. Staff and volunteers who have not received training are expected to identify themselves to their supervisors so that training can be arranged.

Principle 8 – Openness

8.1  Individuals should be able to acquire information about the MS Society’s policies and practices without unreasonable effort.

8.2  The information made available will include:

  • (a) contact information for the person who is accountable for the MS Society’s policies and practices and to whom complaints or inquiries can be forwarded;

8.3  The MS Society will make information about its Privacy and Confidentiality Policy and its practices available in a variety of ways which may include notices on its web site, newsletters, direct marketing pieces, fund raising brochures, and the Opal Information System.

Principle 9 – Individual Access

9.1  If requested to do so in writing, the MS Society will inform an individual whether or not it holds Personal Information about the individual. Before allowing access to any information, the MS Society will confirm the identify of the individual requesting access to his/her Personal Information. In addition, the MS Society will, if requested in writing, provide an account of the use that has been made or is being made of this information and indicate the third parties to which it has been disclosed.

9.2  An individual will be required to provide sufficient information to permit the MS Society to provide an account of the existence, use, and disclosure of Personal Information. The information provided will only be used for this purpose.

9.3  When indicating the third parties to which it has disclosed Personal Information about an individual, the MS Society will attempt to be as specific as possible.

9.4  The MS Society will respond to an individual's request within a reasonable time and at minimal or no cost to the individual. The MS Society will inform the individual of the approximate costs before processing the request. The requested information will be provided or made available in a form that is generally understandable. For example, MS Society abbreviations and/or codes used to record information will be explained.

9.5  Response time to the request will be as quickly as possible and no later than 30 days after receipt of the request. The normal 30-day response time can be extended for a maximum of 30 additional days, if required by the circumstances. If the MS Society extends the time, the individual making the request must be notified within 30 days of the date on which the MS Society received the request from the individual.

9.6  When an individual successfully demonstrates the inaccuracy or incompleteness of his/her own Personal Information, the MS Society will amend the information as required. Depending upon the nature of the information challenged, amendment involves the correction, deletion, or addition of information. Where appropriate, the amended information will be transmitted to third parties having access to the information in question.

9.7  When a challenge is not resolved to the satisfaction of the individual, the MS Society will record the substance of the unresolved challenge. When appropriate, the existence of the unresolved challenge will be transmitted to third parties having access to the information in question.

9.8  In addition, the MS Society will inform the individual that he/she may wish to take the complaint to the office of the Privacy Commissioner of Canada and provide information on how to reach that office which is located at 112 Kent Street, Place de Ville,Tower B, 3rd Floor,Ottawa, Ontario K1A 1H3 The website is www.privcom.gc.ca

Principle 10 – Challenging Compliance

10.1  The MS Society has procedures in place to receive and respond to complaints or inquiries about its policies and practices relating to the handling of Personal Information.

10.2. The MS Society will inform individuals who make inquiries or lodge complaints of the existence of relevant complaint procedures.

Appendix I

Opal Information System Data Sharing Principles

Approved by the National Board of Directors, June 9, 2001

Opal Project Objective

To provide an integrated customer relationship management system throughout the Multiple Sclerosis Society of Canada (MS Society) to enable a high degree of collaboration amongst volunteers and staff and thereby increase our capacity to find a cure for MS and to enable people affected by MS to enhance their quality of life.

Opal Data Sharing Principles

  • The MS Society will comply with applicable privacy legislation and will respect the rights of individuals to be removed from the Opal Information System upon their request.

  • In addition to limiting access to information to authorized users only, the MS Society will provide further security over sensitive Personal Information and restrict access to this data to authorized Client Services (formerly Individual and Family Services) users.

  • Members of the MS Society whose Personal Information is recorded in the Opal Information System will not be solicited for donations to the MS Society solely on the basis of their membership without their express prior consent.

  • Within the MS Society, individuals will be able to self-determine their desired level of interaction and participation in MS Society programs and events.

  • The MS Society will provide equal access to local and organization- wide statistical data recorded on the Opal Information System on an aggregate basis.

Appendix II

Multiple Sclerosis Society of Canada Privacy Forms and Statements

The guiding principles for the statements that we need to have on MS Society documents and forms are the following:

  • We need to tell people why we are collecting information.

  • We need to tell people we are protecting the information they give us.

  • We need to tell people how they can obtain more information about our Privacy Policy and how they can make a complaint.

    Following are a number of frequently used forms statements that have been developed for use where necessary or appropriate on MS Society documents and forms. If you require other statements or have questions about the statements, chapters can contact their division office. Assistance is also available from the National Privacy Officer at 1-866- 922-6065 or priv@mssociety.ca

    Please note: The size of type for these statements should be large enough to be reasonably read depending upon the size of the document and the target audience.

 

Multiple Sclerosis Society of Canada Release of Information Form

TO WHOM IT MAY CONCERN

I, ___________________________________________________ hereby (Print name)

give my permission to the Multiple Sclerosis Society of Canada to release Personal Information including Personal Health Information currently on file with the Multiple Sclerosis Society of Canada to

____________________________________________________ (name of authorized individual, organization or company)

I wish to place the following restrictions on the release of this information:

DATED AT ___________________, in the Province of ______________ this _________________ day of ________________, _____.

______________________________________ (Signature or mark) ______________________________________ (Address) ______________________________________ ______________________________________

In addition, please indicate if representatives of the Multiple Sclerosis Society of Canada can identify themselves as a representative from the MS Society when contacting you and/or leaving information to initiate a return call.

I, ________________________, (print name) authorize and permit representatives of the Multiple Sclerosis Society of Canada to identify themselves as calling from the MS Society when returning my telephone calls or contacting me by telephone.

_____________________________ (Signature or mark)

The Multiple Sclerosis Society of Canada collects personal information about its clients to provide services, provide information about programs and meetings, and to compile anonymous statistical information. By completing this form, you acknowledge and consent to the collection and use by the MS Society of your personal information for these purposes. If you have any questions about your personal information or the MS Society’s privacy policy, contact the National Privacy Officer at 1-866-922-6065 or priv@mssociety.ca or the appropriate Division Privacy Officer at 1-800-268-7582 or priv-atlantic@mssociety.ca; priv-quebec@scleroseenplaques.ca; priv-ontario@mssociety.ca; priv-manitoba@mssociety.ca; priv-sask@mssociety.ca; priv- alberta@mssociety.ca; priv-bc@mssociety.ca.


Volunteer and Staff Privacy and Confidentiality Agreement

I, the undersigned, _____________________________________________________________

(Name of volunteer or staff person)
acknowledge having received, read and understood the document entitled

Multiple Sclerosis Society of Canada Privacy and Confidentiality Policy and the Implementation Guidelines attached.

I further agree that I will hold in confidence the identities of persons with multiple sclerosis, their Client Services records and will not divulge such information, orally or in writing, without the express consent of the individual concerned and only to those Multiple Sclerosis Society of Canada authorized volunteers or staff whose duties require them to have this information on a “need to know” basis and in addition only to individuals, organizations or companies authorized by the Multiple Sclerosis Society of Canada to have this information to fulfill a service or program.

In the absence of consent, sensitive personal information will not be disclosed.

I further agree to conform to the best of my ability and to take reasonable steps to meet the Multiple Sclerosis Society of Canada’s requirements respecting the marking, control, transmission, reproduction, handling, storage and destruction of records of personal information .

_____________________________ (Signature) _____________________________ (Date) _____________________________ (Address) _____________________________

_____________________________

(Note: All staff and all volunteers who have access to Personal Information and Personal Health Information must sign this agreement when they are hired or become a volunteer and on an annual basis thereafter.)

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Multiple Sclerosis Society of Canada Image/Text Identification Release Form

  •   I hereby give my permission to the Multiple Sclerosis Society of Canada to use the image/ photograph or likeness of me and/or my minor child/children.

  •   I hereby give my permission to the Multiple Sclerosis Society of Canada to use my and/or those of my minor child/children verbal or written quotes, given directly, or taken from another source. State source of quote: ______________________________

  •   I hereby give my permission to the Multiple Sclerosis Society of Canada to release my name or that of my minor child/children in a document where I/he/she/they will be identified as a person with multiple sclerosis.

    I understand that the above-mentioned images, quotes, identifications and related documents may appear in various formats/ publications associated with the Multiple Sclerosis Society of Canada, its divisions or chapters and will be released into the public domain, which may include other outside media, to promote the MS Society and its fundraising and awareness efforts.

    I understand that the above-mentioned documents may appear on the Multiple Sclerosis Society of Canada website and will therefore be released into the public domain.

    Instructions: Please print your name and sign below. If permission is being given for a minor child or children (18 and under), please print his/her/their name(s) and sign as parent or guardian

    1.________________________________________ Name of minor child – if applicable

    2. ________________________________________ Name of minor child – if applicable

    3. ________________________________________ Name of minor child – if applicable

    ___________________________________ ________________________________

Name Signature

Dated at, ____________________, in the Province of _____________________

Date: ________/ __________/ _________ Day Month Year

Please sign and return by fax or scan and send by email to:
MS Society contact: _______________________________
Fax # _______________________ Email _____________________________

General statement for all forms

1. Requesting e-mail address usage permission – use on all forms on which you request e-mail addresses

□ I give the MS Society of Canada permission to contact me by e-mail.

Statements for membership forms

1. Advising members of how information is used and of complimentary memberships

The Multiple Sclerosis Society of Canada will use your personal information to compile mailing lists for newsletters, information about programs and meetings and to compile anonymous statistical information.

(You can use the following if your division/ chapter/ unit provides complimentary memberships.)

People with MS may become members of the MS Society free of charge. If you have MS and you wish to become a member, please check here □ Your personal information will be kept confidential.

2. Advising members their membership information may be shared with other members of the Multiple Sclerosis Society of Canada.

From time to time the Multiple Sclerosis Society of Canada will provide certain personal information to other members or the purposes of soliciting proxy votes for our Annual General Meetings or for soliciting signatures for nominations to the Board of Directors. The information provided to other members is limited to the member’s name, home address and home phone number.

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Statement for fax cover sheets

(Can be used as needed for confidential e-mails, letters and memos)

This message is intended only for the addressee. It may contain privileged or confidential information. Any unauthorized disclosure is strictly prohibited. If you have received this message in error, please notify us immediately so that we may correct our internal records. Please then delete or destroy the original message. For information about the Multiple Sclerosis Society of Canada’s Privacy Policy, please visit www.mscanada.ca or contact priv@mssociety.ca.

Statements for client forms

1. Advising clients how information is used

The Multiple Sclerosis Society of Canada collects personal information about its clients to provide services, provide information about programs and meetings, and to compile anonymous statistical information. By completing this form, you acknowledge and consent to the collection and use by the MS Society of your personal information for these purposes. If you have any questions about your personal information or the MS Society’s privacy policy and procedures, please contact our Privacy Officer, (insert name of person responsible for privacy at either chapter or division level) at (insert phone number for privacy officer and e-mail address).

Statement for volunteer forms

1. Advising volunteers of the MS Society Privacy Policy

The MS Society collects the personal information of volunteers like yourself for the purpose of communicating to you information about the MS Society and its programs. By completing this form, you acknowledge and consent to the collection and use by the MS Society of your personal information for these purposes. If you have any questions about your personal information, or the MS Society’s privacy policy please contact our Privacy Officer, (insert name of person responsible for privacy at either chapter or division level) at (insert phone number for privacy officer and e- mail address).

Statements for fundraising forms

1. Privacy statement for use on all event registration forms

The Multiple Sclerosis Society of Canada collects your personal information for the purpose of communicating to you information about the MS Society, its programs and fundraising activities. By completing this form, you acknowledge and consent to the collection and use by the MS Society of your personal information for these purposes. If you have any questions about your personal information or the MS Society’s privacy policy, contact our Privacy Officer, (insert name of person responsible for privacy at either chapter or division level) at (insert phone number for privacy officer and e-mail address).

2. Privacy statement for use with national direct marketing communications documents

The Multiple Sclerosis Society of Canada collects personal information for the purpose of communicating to you information about the MS Society, its programs and fundraising activities. If you have any questions about your personal information or the MS Society’s privacy policy, please contact the Privacy Officer at at 1-866-922-6065 or at priv@mssociety.ca.

3. Informing national direct mail donors of “opt out” option.

From time to time, the MS Society of Canada exchanges donor names and mailing addresses with other charitable organizations. If you do not wish to have your personal information exchanged with other charities, please check here.