Section 1 – What do you want OIPC to review or investigate?

Please identify the name and contact information of the public body/custodian/organization.

Public Body/Custodian/Organization Name

Address

Address Line 1

City

State

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Name of Contact Person

Phone

File Number (if applicable)

Please identify the name and contact information of the public body/custodian/organization.

I made an access to information request:

No Response: The time limit for responding to my request has expired and I have received no reply.
Time Extension: I received notice from the Public Body/Custodian/Organization that the response due date for my request has been extended. I dispute the need for the extension.
Search: The search conducted for records was not adequate or failed to locate records believed to exist.
Fees: I received notice that fees apply. I question how the fees have been calculated
Fee Waiver: I requested a fee waiver and have been denied. I dispute this decision.
Refused Access: I have been refused access to all or part of the records requested. I dispute the decision to withhold information that I requested.
Other (please specify):

I requested a correction to my personal or health information:

No Response: The time limit for responding to my request has expired and I have received no reply.
Correction Denied: I dispute the decision to refuse my request.

I have been notified that my personal/business information will be released to an applicant who made an access request under the Freedom of Information and Protection of Privacy Act.

Third Party: I dispute the public body’s decision to give an applicant access to my information.

I believe my personal information has been improperly collected, used or disclosed:

Collection: My personal/health information has been collected in contravention of Alberta’s privacy laws.
Use: My personal/health information has been used in contravention of Alberta’s privacy laws.
Disclosure: My personal/health information has been disclosed in contravention of Alberta’s privacy laws.

Section 2 – How can we contact you or your representative?

The information in this section will be used to contact you or your representative for this review/investigation. Correspondence will be sent to the address provided below. If your contact information changes, you must complete a “Change of Contact and/or Address for Service” Form to update information in this section.

Are you submitting this request for review/filing this complaint on behalf of a minor?

Yes, I am and I am the guardian of the minor (see section 20 of the Family Law Act).

Your Information

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Last Name

First Name

Address

Address Line 1

City

State

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Daytime Phone Number

Fax Number

Email

May a message be left at your daytime phone number?

Yes
No

Representative Information (complete only if you are represented by another person)

I authorize the following person to act on my behalf and to receive any personal information about me, as necessary, for the purposes of this review

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Last Name

First Name

Address

Address Line 1

City

State

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Daytime Phone Number

Fax Number

Email

May a message be left at your daytime phone number?

Yes
No

Section 3 – Is your request/complaint complete?

Before you send your form to the OIPC, please check if you have attached the relevant documentation to support your request for review/complaint.

Did you attach a copy of the request that you made to the public body, custodian and/or organization (access, correction or fee waiver)?
Did you attach a copy of the correspondence you received from the public body, custodian and/or organization in response to your request (e.g., time extensions, fee estimates, response on fee waiver request or response to access/correction request)? [Please do not attach copies of the records received in response to your access request from the Public Body/Custodian/Organization]
Did you attach a copy of the public body’s notice to you that your personal/business information would be released to an applicant under the FOIP Act?
Did you attach a letter describing the facts or details that support your complaint that your personal/health information has been collected, used or disclosed in contravention of Alberta’s privacy laws? Does your letter describe any actions you have taken to resolve your privacy concerns?

Section 4 – Your Signature and Statements

I confirm that all of the information contained in this Form and attachment(s) is accurate to the best of my knowledge. I also confirm that I understand this Form and all attachments will be provided to the public body, custodian and/or organization concerned. I acknowledge I am required to keep my contact and address information up-to-date and, if I fail to do so, this review may not proceed.

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Signature

Date / Time

Section 5 – Submitting to the OIPC

Choose one of the following three ways to submit this form:

Mail: Send this completed and signed form along with the attachments by mail to:

Edmonton Office

Office of the Information and Privacy Commissioner
Suite 410, 9925 109 Street NW
Edmonton, AB T5K 2J8

Calgary Office

Office of the Information and Privacy Commissioner
2460, 801 – 6 Avenue SW
Calgary, AB T2P 3W2

Fax: Send this completed and signed form along with the attachments to (780) 422-5682 or
(403) 297-2711
Email: Send this completed, signed and scanned form along with the attachments to Complaint_Review@oipc.ab.ca (capital letters not required)

Request for Review/Complaint Form

Section 1 – What do you want OIPC to review or investigate?

Section 2 – How can we contact you or your representative?

Your Information

Section 3 – Is your request/complaint complete?

Section 4 – Your Signature and Statements

Section 5 – Submitting to the OIPC

www.oipc.ab.ca

Office Locations

Office of the Information and Privacy Commissioner (Edmonton)

Office of the Information and Privacy Commissioner (Calgary)

Hours of Operation

Monday to Friday
8:15 am - 4:30 pm

Media Requests

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