Informed Consent for Disclosure of Personal Information

Informed Consent for Disclosure of Personal Information form (Word 52 KB)

For more information, please see our guidelines on Collection of Personal Information, Use of Personal Information, and Disclosure of Personal Information.

*Note to University of Alberta departments: please modify the Informed Consent for Disclosure of Personal Information form for your specific circumstances. 

Download the form, open it in Microsoft Word, and use the Protect Form command on the Forms toolbar to edit the form.

Consider modifying the form in the following ways:
- include your department name and logo
- fill in information for consents for disclosure you regularly request
- remove or include Date of Birth and Student ID fields as required for identification purposes
- modify the Protection of Privacy statement to reflect the purpose for which you are requesting the consent and include contact information for someone in your office who can answer questions about the disclosure of the information (for staff turnover reasons use a position title rather than an individual's name)
- change the footer to your department name and the date you modified the form

Please contact the Information and Privacy Office if you have any questions about how to modify this form or if you would like our staff to review your modifications.

Updated April 2007

Mailing address:
Ring House 4
University of Alberta
Edmonton, AB T6G 2E1

Phone: (780) 492-9419
Fax: (780) 492-6571