PUBLIC SERVANT'S QUESTIONNAIRE
The following questions are based upon the CANADIAN CHARTER OF RIGHTS AND FREEDOMS and are necessary in order that this individual may make a reasonable determination concerning divulgence if information to this agency.
1. Name of public servant ___________________________ 14. What will be the effect upon me if I should choose to not
2. Residence address _______________________________ answer any part or all of these questions? ________________
City, Prov., PC _________________________________ __________________________________________________
3. Name of department of government, bureau, or agency by 15. Name of the person in government requesting that this
which public servant is employed ___________________ investigation be made? _______________________________
______________________________________________ 16. Is this investigation 'general'? ______ Or is it 'special'? _____
Supervisor's name _______________________________ __________________________________________________
4. It's mailing address ______________________________ Note: By 'general' is meant any kind of blanket
City, PC _______________________________________ investigations in which a number of persons are involved
5. Will public servant uphold the CANADIAN CHARTER because of geography, type of business, income, etc. By
OF RIGHTS AND FREEDOMS? ___Yes ___No 'special' is meant any investigation of an individual nature
6. Did public servant furnish proof of identity? ___Yes ___No in which others are not involved
7. What was the nature of proof? ID ___________________
No. ___________________________________________ 17. Have you consulted, questioned, interviewed, or received
Badge No. _____________________________________ information from a third party, relative to this investigation?
8. Will public servant furnish a copy of the law or ___Yes ___No
regulation, which authorizes this investigation?___Yes ___No 18.If yes, the identity of such third parties __________________
9. Will the public servant read aloud the portion of the law 19. Do you reasonably anticipate either a civil or criminal
authorizing the questions he will ask? ___Yes ___No action to be initiated or pursued based upon any of the
10. Are the answers voluntary? _____ Or mandatory? _____ information that you seek? ___Yes ___No
11. Are the questions to be asked based upon a specific law or 20. Is there a file of records, information or correspondence re-
regulation? _____ Or are they being used as a discovery lating to me being maintained by this agency? ___Yes ___No
process? _______________________________________ 21. Is this agency using any information pertaining to me,
12. What other uses may be made of this information? _____ which was supplied, by another agency or government
______________________________________________ source? ___Yes ___No If Yes, which? __________________
13. What other agencies may have access to this information? __________________________________________________
______________________________________________ 22. Will the public servant guarantee that this information in
______________________________________________ these files will not be used by any other department other
______________________________________________ than the one by whom he/she is employed ___Yes ___No
If any request for information to me is received from any person or agency, you must advise me in writing before releasing such information. Failure to do so may subject you to possible civil or criminal action as provided.
AFFIRMATION BY PUBLIC SERVANT
I swear (or affirm) that the answers I have given to the foregoing questions are complete and correct in every particular.
Signed ___________________________________________ Print Name ___________________________________________
Must be signed in ink and the signature should be witnessed by two people. Citizen may administer an oath if he so desires.
Witness __________________________________________ Witness ______________________________________________
Print Name _______________________________________ Print Name ___________________________________________
WhereasCriminal Code, "Section 126. (1) Disobeying a statute - Every one "who, without lawful excuse, contravenes an Act of Parliament by willfully doing "anything that it forbids or by willfully omitting to do anything that it requires to be "done is, unless a punishment is expressly provided by law, guilty of an "indictable offence and liable to imprisonment for a term not exceeding two "years."
And Whereas Criminal Code, "Section 337. Public servant refusing to deliver "property - Every one who, being or having been employed in the service of Her "Majesty in right of Canada or in right of a province, or in the service of a "municipality, and entrusted by virtue of that employment with the receipt, "custody, management or control of anything, refuses or fails to deliver it to a "person who is authorized to demand it and does demand it is guilty of an "indictable offence and liable to imprisonment for a term not exceeding fourteen "years.":
FOR PUBLIC SERVANT USE ONLY
IF PUBLIC SERVANT REFUSES TO COMPLETE AND ENDORSE AS DEMANDED, PLEASE INDICATE SO
please print refused and have witnessed witness
DO NOT USE THIS AREA - IN HOUSE USE
FOR INTERVIEW PURPOSES ONLY
EVIDENCE OF REFUSAL TO COMPLETE AND ENDORSE AS DEMANDED
OF government official
First Witness Second Witness