1. Institution

2. Description of Information to be Collected:

3. Authority for Collection:



4. Manner of Collection:

(i) directly from the individual to whom the information relates.

(ii) indirect collection pursuant to s.39(1) FIPPA/ s.29(1) MFIPPA

5. Anticipated number of individuals in respect of whom Waiver is sought:

6: Use of Personal Information Collected:

(i) Describe Purpose of Collection:

(ii) S.41, 42 FIPPA/s.31, 32 MFIPPA Authorization for Use: (insert section and paragraph number)

(iii) Use listed in Directory

Yes

No(explain)

7. Reason for Waiver:

(i) Reason

Notification Frustrates Purpose of Indirect Collection

Statutory Authority for Indirect Collection

Administrative Burden/Cost of Notification

Authorization of Commissioner

Implied Consent

Collection is from another Institution which has notified Individual

Other (explain)

(ii) Explain why notification cannot be given.

8. Other material attached:

Date:

Head of Institution