This sheet appears as the first page· in your binder. It does not have a location number.

1. Locate on the Amendment Record sheet the number that corresponds to the amendment number of the Manuals Amendment Notice.
2. Enter the date (month, day, year) found on the Amendment Notice next to the appropriate number on the Record sheet.
3. Note any previous ·amendments which may be missing and contact the Manuals Unit.
4. Remove old pages (if any); add new pages as per listing on Amendment Notice.
5. Destroy old pages and Notice. The Manuals unit maintains the manuals' History Files.

1. Turn to subject index (0004).
2. Look up the desired subject.
3. Turn to the indicated location numbers.
4. If unable to find· a subject, turn to the table of contents (0003).

For example

C D - 0 4 0 2

C D - prefix for Case Information

04 is the Section number

02 is the Subject number

For distribution concerns, notify:

For details, see location numbers indicated.

Details follow.

It must be emphasized that the guidelines presented in the manual are in all instances subject to the provisions of existing legislation. Child abuse and adoption information continue to be subject to the special provisions contained in the Child and Family Services Act. Health records continue to be subject to the Health Disciplines Act, the Mental Health Act, and the Public Hospitals Act.

Retention and destruction schedules are also subject to existing legislation (e.g., as in the Young Offenders Act).

The provisions of this manual apply only to client records and pertain to all client information collected or originated by the Ministry as we11 as by all agencies and services operated, funded or Licensed by the Ministry. Examples of such agencies include:

• transfer payment agencies,
• children's services advisory groups,
• other comparable bodies handling Ministry client information.

This manual deals with collection, storage, disclosure and subject access to information.

1. There must be a clearly justifiable and documented purpose for:
   • obtaining information about a subject, and
   • sharing it with a person other than the subject.

   The information collected should be relevant to the service provided.

2. Individuals should have access to personally identifiable information about themselves.
3. Every person's right to privacy should be recognized and protected to the greatest extent possible, consistent with public interest.

   The right of privacy extends to third parties, including those who provide information, as well as to the subject of the record.

4. Before releasing personally identifiable information about a person, written consent must ba obtained subject to certain exceptions. This includes the disclosure of the identity·of third parties providing information.
5. There must be consistency and uniformity in the protections established to safeguard confidentiality of personal information contained in client files, including social, financial and health information.
6. Decisions on access to and disclosure of personal information should be based on:
   • a consideration of the client's best interest,
   • protection of the client's right privacy, and
   • protection of the public interest.
7. Personal information should be disclosed in a manner which ensures that the subject is able to comprehend the information and that the fact of disclosure is a meaningful exercise.

• employed by the Ministry or ·agency who is providing, or has provided, care or service to a subject as a part of a directly-related Ministry-run or Ministry-funded or licensed program, or
• providing, or has provided, care or service within the same program and same organization as the subject's care or Service Provider.

A foster parent with a Children's Aid Society is considered an affiliated care provider.

Whatever body collects or originates the information and which is, therefore, subject to the duties. and constraints imposed by legislation.

• both parents where both have custody of the child;
• one parent, where that parent has lawful custody of the child or the other parent is unavailable or unable to act; or
• another individual, where that individual has lawful custody of the child.

• interviews or written forms,
• the provision of service or therapy, or
• the making of reports or evaluations,

• the information to which access is granted,
• the purpose for which access is granted, and
• the effective period of consent.

For details, see location numbers indicated.

Detail's follow.

• a subject's request for service, or
• the agency in determining the need for provision of service (e.g., CAS protection investigation).

• the purpose for which personal information will be gathered, and
• the types of information to be gathered.

Where possible and appropriate, personal information will be gathered from the subject himself/herself, or the parents if the subject is under 12 years of age.

• the purpose for which information will be gathered and the types of information to be gathered;
• rights of access to the subject's records by the subject, agency staff and others;
• the right to have errors or omissions in the subject's record corrected;
• the procedures for appeal of agency decisions to withhold or limit access to the subject's record; and
• agency policies regarding collection of information.

1. Information deemed by the Service Provider as sensitive and potentially harmful.

   Decisions regarding access or disclosure must be made with consideration to whether the information is harmful at the time of the request for access or disclosure.

2. Information gathered from parents and/or third parties that is designated as inaccessible to the subject.
3. Information gathered from the subject in the provision of counselling services, where the subject between 12· and 16 years has not consented to parental access.
4. All other information held relating to the subject.

Details follow.

Machine-readable cards, tapes or discs which contain personal information should be subject to the same security precautions as records in paper form. These restrictions apply to all media including video and audio tapes.

Information should be stored so that it may be used effectively by the appropriate program staff while at the same time remaining secure from unauthorized access.

Details follow.

• to comply with the legal requirements of various Acts and Regulations which dictate that records be retained for prescribed periods of time;
• to facilitate provision of service at a future date;
• to provide historical data for future identification or verification of facts;
• to provide material for research.

Ministry-operated programs should refer to the Approved Records Schedule prepared by Records Management Section.

• the date the material was sent and,
• a second date specifying when the material must be destroyed (where the retention period is established by legislation).

Details follows.

1. Provision should be made for an annual review to identify the records to be destroyed in accordance with the retention schedules applicable to the agency's records.
2. Procedures established for packaging and handling records prior to destruction must ensure adequate protection against access by unauthorized persons.
3. Records should be destroyed by a pulping, shredding or burning process.
4. Records should be destroyed in the presence of authorized agency staff.
5. Unless contraindicated by relevant legislation, a register should be established and maintained which identifies all records which have been destroyed.

   Note:

   In the case of Ministry-run· programs, refer to the Ministry Administration manual.

For details, see location numbers indicated.

• what information is to be disclosed,
• the purpose of disclosure,
• to whom the record is to be disclosed,
• the effective period of consent, and
• whether the consent authorizes further disclosure by the person receiving the information, and if so, to whom and for what purpose.

  Note:

  The effective period of the consent is normally determined by the purpose for which disclosure is being granted. When the purpose is satisfied, the consent lapses. However, where consent to disclosure, is granted for purposes such as research studies, which could span a number of years, such consent should stipulate that it is effective for a specific time period (e.g., for two years).

1. Has the capacity to understand and appreciate the nature and consequences of giving, or withholding the consent;

   (Thus the Service Provider has to satisfy himself/herself, through questioning or discussion, that the subject fulfills this requirement).

2. Is reasonably informed as to the nature and consequences of disclosure and any alternatives to the action;

   (Informing the subject in a manner suitable to his/her understanding is essential).

3. Gives the consent voluntarily, without coercion or undue influence;

   (The above implies without threat of harm or hope, of favour).

4. Has been advised that he/she may obtain independent advice and has been, given a reasonable opportunity to do so.

   (If someone else has provided advice, the Service Provider is not seen as the only influence on the consenter. Obtaining independent advice, however, is not mandatory).

1. the subject, where the subject is 16 years of age or older;
2. the child's parents, where both have custody of the child and the child is under 16 years of age;
3. one parent of the child, where that parent has lawful custody or the other parent is unavailable or unable to consent and the child is under 16 years of age; or
4. another person having lawful custody where the subject is not yet 16 years old.

The assesssment must be less than one year old and in written form.

1. The subject's parents may designate the information gathered from them as unavailable to the child, and. the subject is under 16 years of age;
2. The Care Provider may withhold parts of the record from the subject where the subject is under age 16, or provide a summary on the basis of the Care Provider's judgement full access would be likely to cause physical or emotional harm to the-subject; or
3. The Care Provider may withhold parts of the record from, the Subject on the basis of the care provider's judgement full access would be likely to cause physical or emotional harm to a third party, or violate the privacy of a third party.

Exceptions to this right of access follow:

1. A subject age 12 or older may refuse to give written consent for disclosure of information gathered in the course of the provision of counselling services;
2. The Care provider may withhold parts of the record from the parent, where the parent is under age 16 or provide a summary, on the basis of the Case Provider's judgement, full access would be likely to cause physical or emotional harm to the subject or another person, or would violate the privacy of another person.

1. Its own employees who are the subject's Care or Service Providers while the agency is treating or serving the subject, where such information is necessary in the performance of their duties.
2. A record-keeper of the agency.
3. An employee of the agency who is responsible for performing a study or review for internal agency use involving the subject's information.
4. An employee of the agency, when the subject is no longer in treatment or receiving service, to the extent needed to:
   • carry out internal reviews,
   • handle the record in accordance with retention schedules, or
   • engage in follow-up activity concerning the subject.
5. Students and volunteers, where the information is deemed by agency supervisory staff to be necessary in the performance of their duties.
6. An affiliated Care or Service Provider, including:
   • a Service Provider who works within the same or a related program as the subject's Service Provider;
   • a worker in another program who is concerned with the care of the subject as part of a review team engaged in service planning for the subject (e.g., a teacher), with the permission of the subject's Care or Service Provider; or
   • professional advisors of the Care or Service Provider who require access to the person's record for the performance of their duties.
7. To a Peace Officer, or a person providing medical treatment, where failure to disclose is likely to cause the subject or other person serious physical or emotional harm or where the need for disclosure is urgent.
8. The police, in the course of an investigation of alleged child abuse committed by or against the subject. Also in the case of any investigation initiated by the Service Provider.
9. In rare instances, an external researcher, as provided for in 0305.

1. A Ministry employee who is responsible for:
   1. conducting a financial or program audit, review or study involving a subject's record;
   2. monitoring a program provided by an agency (e.g.. Program Supervisor).
   Because of the sensitivity of the information, it is Ministry policy that staff:
   • be chosen for their experience, or qualifications in reviewing programs,
   • review the subject's information in the presence of staff of the program/unit being reviewed, and
   • use their right of direct access with discretion.
2. Anyone authorized under legislation, (e.g., the Ombudsman or Coroner).
3. Anyone authorized by a court order or search warrant. If files are subpoenaed, they must be taken by agency staff to Court.
4. Legal counsel for the Ministry.
5. Children's Aid Societies in situations where a child is or may be in need of protection, or is, may be or may have suffered abuse.

The carrying out of this responsibility may on occasion require disclosure of the identity of persons receiving care or service, or certain information contained in a subject's record to the board, or a designated committee of the board. Such disclosure should occur only in those circumstances where it would otherwise be impossible for the board to carry out its function and where the disclosure has been requested by the board or designated committee as a whole.

Disclosure should not be made to an individual board member unless:

• that director is involved in the provision of care or service in another capacity, and
• has a right to such disclosure in that capacity.

• they understand and will respect confidentiality provisions and,
• unless required by law, they will not disclose personal information on a subject.

Agency policy and procedures should identify which staff, students and volunteers may have access to client records or information contained in them.

Because of the sensitivity of the information, it is Ministry policy that staff:

• be chosen for their experience or qualifications in reviewing; programs,
• review the subject's information in the presence of staff of the program/unit being reviewed, and
• use their right of direct access with discretion.

Details follow.

1. A discussion of the general problem under investigation, including a review of previous research where relevant;
2. The specific objectives of the proposed study;
3. The overall research design and specific research methods to be used, including projected use of agency personnel;
4. In the case of projects that would require data collection directly from clients, a description of procedures to be used in dealing with clients and copies of all specific data collection, instruments to be employed with-clients;
5. A draft consent form for release of personally identifiable client information and/or client participation in the project;
6. An outline of the proposed analysis;
7. A plan for reporting findings which specifies the number and types of reports to be produced and the proposed distribution of each,
8. A discussion of any potential, risks-to clients inherent in agency participation in the project;
9. A discussion of the specific benefits that would accrue to the agency, agency clients, or the public, from agency participation in the study;
10. Curriculum vitae for:
    • the principal investigator (and, in the case of a post-graduate student working on a thesis, supporting documentation from the supervising professor); and
    • any other project staff who would be involved in reviewing personally identifiable client information and/or collecting data directly from clients; and
11. where applicable, the recommendation or report of the sponsoring organization's ethics committee.

1. The program in which the information was collected;
2. The type of information (e.g., names and addresses of clients, individual case files, test scores of clients, computer tapes) being requested;
3. The size of the desired sample; and
4. Any criteria that would have to be used in selecting the sample (e.g., age of the client, type of service provided, period of service delivery)

• to assess whether there is any basis for agency interest, and
• to determine if it is feasible to satisfy the independent researcher's needs without releasing personally identifiable information (e.g., by providing copies of records from which all personally identifiable information has been removed).

1. Has objectives with direct utility to the agency, its clients or the general public;
2. Does not require client information that the agency considers to be too personally sensitive, or to entail other significant risks for clients;
3. Has been planned and would be carried out in accordance with appropriate technical standards;
4. Is, from the agency's perspective, feasible; and
5. Is, therefore, likely to produce results with clear public benefit without any significant risk to clients.

   Note:

   Where the agency agrees to participation in a project, a formal agreement should be signed outlining the purpose of the research and the terms and conditions of access.

Where an independent researcher wishes to collect data directly from clients and the agency decides to assist the researcher, the agency should:

1. Mail questionnaires to clients, asking if they wish to participate in the study and specifying that a decision not to participate would in no way affect their receipt of service,
2. Contact clients to obtain their consent for the researcher to contact them directly, or
3. Contact clients, inviting them to contact the researcher if they wish to participate in the study.

• does not require an inappropriate expenditure of agency time and/or money, and
• is likely to result in clear public benefit, without significant risk to the client.

Details follow.

Disclosure refers to the viewing of all or part of the record and/or obtaining copies of the desired material by a third party. The procedure for releasing information is the same for both categories.

1. Agency Staff Arrange for an appointment with the person seeking access or disclosure.
2. Agency Staff Review the file with the person seeking access or disclosure, giving appropriate interpretation to ensure that the information is understood to the greatest extent possible.

   Note:

   1. The staff member should be present at all times while the record is being examined.
   2. The person seeking access or disclosure should be given a reasonable amount of time to peruse the material and make notes, if desired.
3. Person seeking access or disclosure Acknowledge in writing that a specific record or portion of a record has been seen.

   Note:

   All instance's of access or disclosure of a record must be recorded clearly on the record except when it is used by authorized staff.

• the time and costs involved in locating, retrieving, preparing and copying the record,
• whether payment of costs will cause financial hardship to the person requesting the record,
• whether access or disclosure will benefit public health or safety.

  Note:

  Disclosure of information by a Service Provider to another Service Provider is not subject to charge.

All third parties with whom the record has been shared within the preceding year must be notified of the discrepancy.

Where the correction is of a critical nature, and may lead to actions, decisions, or judgements harmful to the subject (e.g., an intelligence assessment of a child based on an accidentally inflated age), third parties with whom the record has been shared prior to this period should also be informed.

Details follow.

• a request for access, to or correction of a record is refused in whole or in part,
• a subject believes that" a Service Provider may have disclosed his or her record without authority.

• include the reasons for the decision, and
• advise the party that the decision may be referred to the CSRB for review.

An extension of-the 30-day period may be permitted in order to:

• obtain information located in another office,
• search for or appropriately examine material included within the information requested, or
• consult with any other office holding the information.

Requests for review must be submitted within 20 days of receiving notice of refusal of access, or in the case of unauthorized disclosure, within 20 days of becoming aware of the disclosure.

The CSRB shall notify the head of the agency or program when a review of the decision has been requested.

• order the Service Provider to grant access to all or part of the record;
• order the Service Provider to make a correction;
• confirm the refusal, if satisfied that the refusal being appealed is justified;
• declare that disclosure was unauthorized, if satisfied that disclosure or unauthorized disclosure took place;
• order the Service Provider to:
  • change procedures for the maintenance and disclosure of the subject's records, or
  • desist from a particular disclosure practice;
• recommend to the Minister that the Service Provider's approval be revoked under Part I of the Child and Family Services Act.

• the person requesting the review,
• the Service Provider, and
• the Minister.

For details, see location numbers indicated.

Detail's follow.

• the-purpose for which information will be gathered, and
• the types of information to be gathered.

Where possible and appropriate, personal information will be gathered from the subject himself/herself.

• the purpose for which information will be gathered and the types of information to be gathered;
• rights of access to the subject's record, by the subject, agency staff or others;
• the right to have errors or omissions in the subject's record corrected;
• the procedures for appeal of agency decisions to withhold or limit access to the subject's record;
• agency policy regarding collection of information.

• Information deemed by the Service Provider as sensitive and potentially harmful to a third party.
• Information gathered from third parties that is designated as inaccessible to the subject.
• All other information held relating to the subject.

  Note:

  See also 0503, Access By Subject.

Details follow.

Machine-readable cards, tapes and discs which contain personal information should be subject to the same security precautions as records in paper form. These restrictions apply to all media including video and audio tapes.

Information should be stored so that it may be used effectively by the appropriate program staff, while at the same time remaining secure from unauthorized access.

Details follow.

• to comply with the legal, requirements of various Acts and Regulations which dictate that records be retained for prescribed periods of time;
• to facilitate provision of service at any future time;
• to provide historical data for future identification or verification of facts;
• to provide material for research.

Ministry-operated programs should refer to the Approved Records Schedules-prepared by Records Management Section.

Details follow.

1. Provision should be made for annual review to identify the records to be destroyed in accordance with the retention schedules applicable to the agency's records.
2. Procedures established for packaging and handling records prior to destruction must ensure adequate protection against access by unauthorized persons.
3. Records are to be destroyed by a pulping, shredding or burning process.
4. Records should be destroyed in the presence of the appropriate agency staff.
5. Unless contraindicated by relevant legislation a register should be established and maintained which identifies all records which have been destroyed.

   Note:

   In the case of Ministry-run programs, refer to the Ministry Administration manual.

For details, see location numbers indicated.

• what information is to be disclosed,
• the purpose of disclosure,
• to whom the record is to be disclosed,
• the effective period of consent, and
• whether the consent authorizes further disclosure by the person receiving the information, and if so, to whom and for what purpose.

  Note:

  The effective period of the consent is normally determined by the purpose for which disclosure is being granted. When the purpose is satisfied, the consent lapses. However, where consent to disclosure is granted for purposes such as research studies, which could span a number of years, such consent should stipulate that it is effective for a specific time period (e.g., for two years).

1. Has the capacity to understand and appreciate the-nature and consequences of giving or withholding the consent;

   (Thus the Service Provider has to satisfy himself/herself, through questioning or discussion, that the subject fulfills this requirement.)

2. Is reasonably informed as to the nature and consequences of disclosure and any alternatives to the-action;

   (Informing the subject in a manner suitable to his/her understanding is essential.)

3. Gives the consent or enters into the agreement voluntarily, without coercion or undue influence;

   (The above implies without threat of harm, or hope of favour)

4. Has been advised that he/she may obtain independent advice and has been given a reasonable opportunity to do so.

   (If someone else has provided advice, the Service Provider is not seen as the-only influence, on the consenter. Obtaining independent advice, however, is not mandatory.)

1. The form of the information to be made available to the subject should be comprehensible to him/her.
2. The subject should have access to factual information, about himself/herself for the purpose of checking accuracy.
3. In all cases, appropriate protection against violation of the privacy of third parties must be ensured; This may require limiting access to personally identifiable information related to parties other than the subject.
4. The agency may withhold information or provide a summary on the basis of the Care Provider's judgement that full access would be harmful to the emotional or physical health-of a third party.

Where there is no executor, the next-of-kin has access.

1. Its own employees who are the subject's Care or Service Providers while the agency is treating or serving the subject, where such information is necessary in the performance of their duties.
2. A record-keeper of the agency.
3. An employee of the agency who irresponsible for performing a study or review for internal agency use involving the subject's information.
4. An employee of the agency, when the subject is no longer in treatment or receiving service, to the extent needed to:
   • carry out internal reviews.
   • handle the record in accordance with retention schedules, or
   • engage in follow-up activity concerning the subject.
5. Students and volunteers, where the information is deemed by agency supervisory staff to be necessary in the performance of their duties.
6. An affiliated Care or Service Provider. This includes;
   • a Service Provider who works within the same or a related program as the subject's Service Provider;
   • a worker in another program who is concerned with the care of the subject as part of a team engaged in service planning for the subject (e.g., a teacher), with the permission of the subject's Care or Service Provider; or
   • professional advisors of the Care or Service Provider who require access to the person's record in the performance of their duties.
7. To a Peace Officer or a person providing medical treatment, where failure to disclose is likely to cause the subject or other person serious physical or emotional, harm or where the need for disclosure is urgent.
8. The police, in the course of an investigation of alleged child abuse committed by or against the subject. Also in the case of any investigation initiated by the Service Provider.
9. In rare instances, an external researcher, as provided for in 0505.

1. A Ministry employee who is responsible for;
   1. conducting a financial or program audit, review or study involving a subject's record; and
   2. monitoring a program provided by an agency (e.g., Program Supervisor).
   Because of the sensitivity of the information, it is Ministry policy that:
   • staff-be chosen for their experience or qualifications in reviewing programs;
   • staff review the subject's information in the presence of staff, of the program/unit being reviewed;
   • staff use their right of direct access with discretion.
2. Anyone-authorized under legislation (e.g., the Ombudsman or Coroner).
3. Anyone authorized by a court order or search warrant. If files are subpoenaed, they must be taken by agency staff to Court.
4. Legal counsel for the Ministry.
5. Children's Aid Societies in situations where a child is or may be in need of protection, or is, may be, or may have suffered abuse.

The carrying out of this responsibility may on occasion require disclosure of the identity of persons receiving care or service, or certain information contained in a subject's record to the board, or a designated committee of the board. Such disclosure should occur only in those circumstances where it would, otherwise be impossible for the board to carry out its function and where the disclosure has been requested by the board or designated committee as a whole.

Disclosure should not be made to an individual board member unless:

• that director is involved in the provision of care or service in another capacity, and
• has a right to such disclosure in that capacity.

• they understand and will respect confidentiality provisions and,
• unless required by law, they will, not disclose personal information oh a subject.

Agency policy and procedures should identify which staff, students and volunteers may have access to client records or information contained in them.

Details follow.

1. A discussion of the general problem under investigation, including a review of previous research where relevant;
2. The specific objectives of the proposed study;
3. The overall research design and. specific research methods to be used, including projected use of agency personnel;
4. In the case of projects that would require data collection directly from clients, a description of procedures to be used in dealing with clients and copies of all specific data collection instruments to be employed with clients;
5. A draft consent form for release of personally identifiable client information and/or client participation in the project;
6. An outline of the proposed analysis;
7. A plan for reporting findings which specifies the number and types of reports to be produced and the proposed distribution of each;
8. A discussion of any potential risks to clients inherent in agency participation in the project;
9. A discussion of the specific benefits that would accrue to the agency, agency clients, or the public, from agency, participation in the study;
10. Curriculum vitae for:
    • the principal investigator (and, in the case of a post-graduate student working on a thesis, supporting documentation from the supervising professor); and
    • any other project staff who would be involved in reviewing personally identifiable client information and/or collecting data directly from clients? and
11. Where applicable, the recommendation or report of the sponsoring organization's ethics committee.

1. The program which collected the information?
2. The type of information (e.g., names, and addresses of clients, individual case files, test scores of clients, computer tapes) being requested;
3. The size of the desired sample; and
4. Any criteria that would nave to be used in selecting the sample (e.g., age of the client, type of service provided, period of service delivery).

• to assess whether there is any basis for agency interest, and
• to determine if it is feasible to satisfy the independent researcher1s needs without releasing personally, identifiable information (e.g., by providing copies of records from, which all personally identifiable information has been removed).

1. Has objectives with direct utility to the agency, its clients or the general public,
2. Does not require client information that the agency considers to be too personally sensitive, or to entail other significant risks for clients;
3. Has been planned and would be carried out in accordance with appropriate technical standards;
4. Is, from the agency's perspective, feasible; and
5. Is, therefore, likely to produce results with clear public benefit without any significant risk to clients.

   Note:

   Where the agency agrees to participation in a project, a formal agreement should be signed outlining the purpose of the research and the terms and conditions of access.

Where an Independent researcher wishes to collect data directly from clients and the agency decides to assist the researcher the agency should:

1. Mail questionnaires to clients, asking if they wish to participate in the study and specifying that a decision not to participate would in no way affect their receipt of service,
2. Contact clients to obtain their consent for the researcher to contact them directly, or
3. Contact clients, inviting them to contact the researcher if they wish to participate in the study.

• does not require an inappropriate expenditure of agency time and/or money, and
• is likely to result in clear public benefit, without significant risk to the client.

In all cases, agencies should obtain the right to review the final report before its release to ensure it contains no personally identifying information.

Details follow.

Disclosure refers to the viewing of all or part of the record, arid/or obtaining copies of the desired material by a third party. The procedure for releasing information is the same for both categories.

1. Agency Staff Arrange for an appointment with the person seeking access or disclosure.
2. Agency Staff Review the file with the-person seeking access or disclosure, giving appropriate interpretation to ensure that the information is understood to the greatest extent possible,

   Note:

   1. The staff member should be present at all times while the record is being examined.
   2. The person seeking access or disclosure should be given a reasonable amount of time to peruse the material and make notes, if desired.
3. Person seeking access or disclosure Acknowledge in writing that a specific record or portion of a record has been seen.

   Note:

   All instances of access or disclosure of a record must be recorded clearly on the record, except when used by authorized staff.

• the time and costs involved in locating, retrieving, preparing and copying the records;
• whether payment of costs will cause financial hardship to the person requesting the record;
• whether access or disclosure will benefit public health or safety.

All third parties with whom the record has been shared within the preceding year must be notified of the discrepancy.

Where the correction is of a critical nature, and may lead to actions, decisions, or judgements harmful to the subject (e.g., an intelligence-assessment of a child based on an accidentally inflated age), third parties with whom the record has been shared prior to this period should also be informed.

Details follow.

• a request for access to or correction of a record is refused in whole or in part,
• a subject believes that a Service Provider may have disclosed his or her record without authority.

• include the reasons for the decision, and
• advise the party that the decision may be referred to the Area Manager for review.

An extension of the 30-day period may toe permitted in order to:

• obtain information located in another office,
• search for or appropriately examine material included within the information requested, or
• consult with any other office holding the information.

The Area Manager shall notify the head of the agency or program when a review of the decision has been requested.

When the appropriate parties have been notified of the review, it is the responsibility of the Area. Manager to investigate both the request for access and the decision, and to attempt to resolve the dispute. Anything said, or any information/document used in the course of such a review is strictly confidential.

• Legislation
  • Family Benefits Act
  • General Welfare Assistance Act
  • Ministry of Community & Social Services Act
• Ministry policy
• Municipal or Band policy

• the purpose for which information will be gathered, and
• the types of information to be gathered.

• the purpose for which information will be gathered and the types of information to be gathered,
• rights of access to the subject's record by the subject, agency staff and others;
• the right to have errors or omissions in the subject's record corrected;
• the procedures for appeal of agency decisions to withhold or limit their access to the subject's record;
• agency policies regarding collection of information.

To facilitate- responses to requests for access or disclosure, it may be advisable to identify information gathered as follows:

1. Information deemed by the Service Provider as sensitive and potentially harmful to third parties.
2. Information gathered from third parties that is designated as inaccessible to the subject.
3. All other information held which relates to the subject.

   Note:

   See also 0703, Access By Subject

Details, follow.

1. the original documents, signed by the subject or provided by the subject, or by third parties, and;
2. records of decisions, recommendations and calculations.

Additional information may be collected and stored as part of the main record or as a separate record, depending upon the policy of the agency.

Such information could include:

1. medical information,
2. information related to the pursuit of spousal or child support,
3. information related to investigation of eligibility,
4. any reference material or information held, separately by the worker.

The Ontario Assistance Program (ONTAP) contains data on persons who are receiving benefits under the Family Benefits Act or the Ministry Act.

The Overpayment Recovery and Follow-up System {ORFUS) contains data on all clients in overpayment when benefits are terminated. Once overpayment is recovered, all information on the client is removed from the system.

The Comprehensive Income Maintenance System (CIMS) encompasses the above three systems (CRS ONTAP, ORFUS) as well as the Municipal Assistance Information Network (MAIN). CIMS supports the administration of the Income Maintenance Legislation and contains data on Income Maintenance applicants and clients.

At the same time, records must be kept in secured areas and not left unattended in areas accessible to unauthorized persons.

Original documents and statutory forms in the subject's record must not be taken out of the agency. Other documents, which may be necessary for home visits must be handled in such a way as to minimize the possibility of loss, theft, or a breach of confidentiality.

1. photocopies of original documents and statutory forms are not generated without a clear, valid reason (e.g., an eligibility review or fraud investigation, CAP approval).
2. photocopies are made by authorized staff in order to minimize the possibility of copies being circulated to unauthorized persons.

• to comply with the legal requirements of various Acts and Regulations which dictate that records be retained for prescribed periods of time;
• to facilitate provision of service at any future time;
• to provide historical data for future identification or verification of facts;
• to provide material for research;
• to provide a record of overpayments to clients.

The five-year period of retention applies to a subject's records in total, or to documentation contained in the record.

Details follow.

• approval by federal authorities and
• archival selection.

• what information is to be disclosed,
• the purpose of disclosure,
• to whom the record is to be disclosed,
• the effective period of consent, and
• whether the consent authorizes further disclosure by the person receiving the information, and if go, to whom and for what purpose.

1. Has the capacity to understand and appreciate the nature and consequences of giving or withholding the consent;

   (Thus the Service Provider has to satisfy himself/herself, through questioning or discussion, that the subject fulfills this requirement.)

2. Is reasonably informed as to the nature and consequences of disclosure and any alternatives to the action;

   (informing the subject in a manner suitable to his/her understanding is essential.)

3. Gives the consent or enters into the agreement voluntarily, without coercion or undue influence;

   (The above implies without threat of harm or hope of favour.)

4. Has been advised that he/she may obtain independent advice and has been given a reasonable opportunity to do so.

   (If someone else has provided, advice, the Service Provider is not seen as the only influence, on the consenter. Obtaining independent advice, however, is not mandatory.)

If a subject is declared incompetent, consent to third party disclosure must be given by the committee, subject to the restrictions detailed in 0704.

1. The form of the information to be made available to the subject should be comprehensible to him/her.
2. The subject should-have; access-to factual information about himself/herself for the purpose of checking accuracy.
3. The subject should have access to information provided by other parties which could affect the eligibility status of the subject to receive benefits.

   In all cases appropriate protection against the disclosure of identity and violation of the privacy of third parties must be ensured.

1. Access to the main file or case history sheet may be restricted because of investigations.
2. Information may be withheld or a summary provided on the basis of the Service Provider's judgement that full access could be harmful to the emotional or physical health of a third party.
3. Legal opinions in the file where solicitor-client privilege may apply are restricted.
4. In the case of medical documentation subject access to the information submitted by his or her physician(s) is given only with the written consent-of the contributing physician(s).
5. Complaints or allegations of fraud received by an agency regarding possible abuse of public funds must be investigated.

   While the allegation remains unsubstantiated, and is under investigation, the investigative information may be recorded in a separate record. This information is not subject to access by the client or his/her- representative. .

   After the investigation has been completed, a final report, indicating whether or not the allegation was substantiated, becomes part of the master file. This report then becomes accessible to the subject, conditional upon any restriction imposed by the complainant or the provider of the information.

   Note:

   1. The names of informants should never be revealed without their expressed consent.
   2. If a decision is made to withhold information, the reasons for the decision must be documented in the record and must be given in writing, to the subject. The subject should also be made aware of the right to have decisions reviewed, (See also 0708),

Where there is no executor, the next-of-kin has access.

Access is also given to provincial/federal auditors in" order to perform, their duties-.

Disclosure will be limited to information necessary to establish or verify eligibility and avoid fraud, or duplication of payments. At the time of the initial application for either type of benefit, the subject must be informed, that essential information can be exchanged between the two systems.

Those representatives not entitled to access to this personally identifying information include:

• individual members of a Municipal or Band Council or District Welfare Board, and
• any Municipal or Band Council not directly responsible for the G.W.A. administration.

Legal counsel for the Ministry may have access to a subject's record.

Information may be disclosed without consent to Children's Aid Societies, in situations where a child is or may be in need of protection, oris, may be, or may have suffered abuse.

Details follow.

1. A discussion of the general problem under investigation, including a review of previous research where relevant;
2. The specific objectives of the proposed study;
3. The overall research design and specific research methods to be used, including projected use of agency personnel;
4. In the case of projects that would require data collection directly from clients, a description of procedures to be used in dealing with clients and copies of all specific data collection instruments to be employed with clients;
5. A draft consent form for release of personally identifiable client information and/or client participation in the project;
6. An outline of the proposed analysis;
7. A plan for reporting findings which specifies the number and types of reports to be produced and the proposed distribution of each?
8. A discussion of any potential risks/to clients inherent in agency participation in the project;
9. A discussion of the specific benefits that would accrue to the agency, agency clients or the public from participation in the study;
10. Curriculum vitae for
    • the principal investigator (and in the case of a post-graduate student working on a thesis, supporting documentation from the supervising professor, and
    • any other project staff who would be involved in reviewing personally identifiable client information and/or collecting data directly from clients; and
11. where applicable, the recommendation or report of the sponsoring organization's ethics committee.

1. The program which collected the information;
2. The type of information (e.g., names and addresses of clients, individual case files, test scores of clients, computer tapes) being requested;
3. The size of the desired sample; and
4. Any criteria that would have to be used in selecting the sample (e.g., age of the client, type of service provided, period of service delivery).

• to assess'whether there is any basis for agency interest, and
• to determine if it is feasible to satisfy the independent researcher!s needs without releasing personally identifiable information (e.g., by providing copies of records from which all personally identifiable Information has been removed).

1. Has objectives with direct utility to the agency, its clients or the general public,
2. Does not require client information that the agency considers to be too personally sensitive, or to entail other significant risks for clients;
3. Has been planned and would be carried out in accordance with appropriate technical standards;
4. Is, from the agency's perspective, feasible; and
5. Is, therefore, likely to produce results with clear public benefit without any significant risk to clients.

   Note:

   Where the agency agrees to participation in a project, a formal agreement should be signed outlining the purpose of the research and the terms and conditions of access.

Where an independent researcher wishes to. collect data directly from clients and the agency decides to assist the researcher, the agency should:

1. Mail questionnaires to clients, asking if they wish to participate in the study and specifying that a decision, not to participate would in no way affect their receipt of service;
2. Contact clients to obtain their consent for the researcher to contact them directly; or
3. Contact clients, inviting them to contact the researcher if they wish to participate in the study;

• does not require an inappropriate expenditure of agency time and/or money, and
• is likely to result in clear public benefit without significant risk to the client.

In all cases, agencies should obtain*the right to review the final report before its release-to ensure it contains no personally identifying information.

Details follow.

Disclosure refers to the viewing of all or part of the record and/or obtaining copies of the desired material by a third party.

The procedure for releasing information is the same for each category.

1. Agency Staff Arrange, for an appointment with the person seeking access or disclosure.
2. Agency Staff Review the record with the person seeking access or disclosure, giving appropriate interpretation to ensure that the information is understood to the greatest extent possible.

   Note:

   1. The staff member should be present at all times while the record is being examined.
   2. The person seeking access or disclosure should be given a reasonable amount of time to peruse the material and make notes, if desired.
3. Person Seeking Access or Disclosure Acknowledge in writing that a specific record or portion of a record has been seen.

   Note:

   All instances of access or disclosure of a record must be recorded clearly on the record except when used by authorized staff.

• the time and cost involved in locating, retrieving, preparing and copying the record,
• whether payment of costs will cause financial hardship to the person requesting the record;
• whether access or disclosure will benefit public health or safety.

The municipal office may:

• obtain a signed consent form from the client, or
• advise the client that he/she will be referred to F.B.A. and the, information will be transferred automatically.

Details follow.

• a request for access to or correction of a record is refused in whole, or in part, or
• a subject believes that a Service Provider may have disclosed his or her record without authority.

• include the reasons for the decision, and
• advise the party that the information that the decision may be referred to the Area Manager for review.

An extension of the 30-day period may be permitted in order to:

• obtain information located in another office,
• search for or appropriately examine material included within the information requested, or
• consult with any other office holding the information.

The Area Manager shall notify the G.W.A. Administrator when a review of their decision has been requested.

When the appropriate parties have been notified of the review, it is the responsibility of the Area Manager to investigate both the request for access, and the decision, and to-attempt to resolve the dispute. Anything said, or -any information/document -used in the •course of such a review, is confidential.