Required fields are marked with an asterisk (*) For more information on the privacy complaint process, please visit the HRM Privacy Policy.In accordance with Section 485 of the Municipal Government Act (MGA), any personal information collected in this form will only be used by municipal staff and, if necessary, individuals and/or organizations under service contract with the Municipality to fulfill the purpose for which it was originally collected, or for a use consistent with that purpose. If you have any questions about the collection and use of your personal information, please call 311 or email contactus@311.halifax.ca Which of the following best describes you? * Halifax Regional Municipality (HRM) Employee Halifax Water Employee Public Please provide your Full Name * First Name * Last Name * What is your preferred method of contact? * Email Phone Email Telephone Are you submitting this complaint on behalf of yourself? * Yes No Submitting on Behalf of Another IndividualIf you are submitting this complaint on behalf of another individual, by completing and submitting this form you confirm that you are authorized to act on the complainant’s behalf.Please provide the following information: Please provide name of Complainant Complainant First Name Complainant Last Name Your relationship to the complainant? Please indicate the date (or approximate date) the incident occurred? If unsure, please skip * Please identify the category of personal information that was involved * Contact information Demographic information Financial status/history Medical status/history Educational status/history Employment status/history Criminal status/history Personal opinion Recordings (video, pictures, audio) Other/additional details (please add to next question) Please specify which personal information was involved if you selected 'other' in the question above or if you would like to include additional details Please only use this field if none of the options apply or you would like to provide additional details.Do not include identifiable personal information. Please identify the type of harm the incident has caused? * Identity theft Physical harm or harassment - e.g., stalking Emotional harm, humiliation, or damage to reputation Financial damage Loss of business or employment opportunities Breach of contract and/or other legal obligations - e.g., from data loss Future breaches - e.g., technical failures Risk to public health or safety Recordings (video, pictures, audio) Other/additional details (please add to next question) Please specify if other impacts may occur or if you would like to provide additional details Please only use this field if you chose "Other" or you want to provide additional details. Do not include identifiable personal information. Are other individuals involved in this complaint? * Yes No Unknown Please provide the name(s) of the individual(s) involved in this complaint Please describe the privacy complaint. * Please include the following details, if known:A description of the privacy incident, including what happenedHow you became aware of the issueAny actions taken so far to address the issue. Submit
