Sexual Misconduct Support and Resource Centre: Expression of Interest to Join the Community Consultation Group (d4900-Em form)

1. First Name
2. Last Name
3. Please identify your preferred communication method, and the details for that preferred method.
   1. Telephone number:
      1. If you prefer being contacted by telephone, may the SMSRC leave you a voicemail?
   2. Email address:
4. Please identify the province/territory of your main residence. This will enable us to ensure the Community Consultation Group includes individuals across the country.
   1. Please check this box if your main residence is in a Northern, rural, or remote area.
5. Please identify the official language in which you would prefer to receive communications (you may select multiple options):
6. Please identify your connection to the Defence community.
   • Cadet
   • Currently serving Canadian Armed Forces (CAF) member
   • Current and former Department of National Defence public service employee
   • Staff of the Non-Public Funds
   • Veteran/former CAF member
   • Families, loved ones, and caregivers of the above
   • Other (specify):

   We encourage applicants from across the Defence community, and recognize the distinct experiences within this community. The purpose of this self-identification is to ensure the groups are representative of the Defence community, and to promote fulsome participation.

   If you are a currently serving CAF member or a Veteran / former CAF member, please identify the following based on your current status, or that upon your release (if applicable):

   Rank:
   (Adm; Gen; LGen; VAdm; MGen; RAdm; BGen; Cmdre; Capt(N); Col; Cdr; LCol; LCdr; Maj; Capt; Lt(N); Lt; Slt; 2Lt; A/Slt; Esgn; NCdt; OCdt; CPO 1; CWO; CPO 2; MWO; Csgt; PO 1; WO; PO 2; Sgt; MBdr; MCpl; MS; Bdr; Cpl; S1; S2; Avr; Cfn; Dmr; Fus; Gdsm; Gnr; Mus; Ppr; Pte; Pte(T); Rfn; Sig; Spr; Tpr; Volt; S3; Pte(B); Pte(R); Rgr; Civilian)

   Force:

   • Regular
   • Reserve

   Element:

   • Air
   • Army
   • Navy
7. Please select which of the following groups you identify with (you may select multiple options):
   • Gender nonconforming
   • Non-binary
   • Indigenous (such as First Nations, Inuit, or Métis)
   • Woman
   • Man
   • Official language minority
   • Person living with disabilities (visible and/or non-visible)¹
   • Member of a racialized group
   • 2SLGBTQI+ (Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Plus)
   • Another identity factor that is not listed above (please specify if you wish to do so):
8. Do you consent to receive updates by email from the SMSRC on our programs and services?  Your response to this question has no impact on your involvement in the SMSRC’s Community Consultation Group.

If you identified an email address in Question 3, we will use that contact information, and you may leave the field below blank. If you would like to receive these updates at a different email address, please identify it below. At anytime, if you wish to withdraw your consent to receiving these updates about SMSRC programs and services, you may unsubscribe by notifying us at SMSRC.Partnerships-Partenariats.CSRIS@forces.gc.ca.

Preferred email address for SMSRC updates:

Privacy Notice Statement

The personal information on this form is collected under the authority of s. 4 of the National Defence Act and will be used by the Sexual Misconduct Support and Resource Centre (SMSRC) for the purpose of creating a Consultation Group(s) which will provide input and recommendations on the development and improvement of SMSRC programs and services.  The personal information collected on this form will be used to ensure the Consultation Group(s) is representative across various criteria, such as location, language, military experience, and gender/gender identity.

The personal information on this form will be used to determine and communicate your participation as a Community Consultation Group member. If you do not participate in an initial Consultation Group, the SMSRC will retain the information on this form so that it can be used in the formation of future Consultation Groups.  If, after submitting your expression of interest, you wish to remove your name from the Community Consultation Group, you may do so by notifying the SMSRC at SMSRC.Partnerships-Partenariats.CSRIS@forces.gc.ca.

Personal information will be used for program administration and may be used for program development, program evaluation, reporting, research, and statistical analysis.

The SMSRC will not use the information you submit, including your contact information, for any purposes other than those described in this privacy notice statement without first obtaining your explicit consent, except when otherwise required by law, which includes the circumstances listed under ss. 8(2) of the Privacy Act.

If you participate in the Community Consultation Group, a program-specific consent form will be provided to you for review and signature. Program officials will review that consent form with you to ensure you understand its contents and how it impacts you.

Personal information collected, as well as its use, disclosure, and retention, is described in Personal Information Bank DND PPU 880 (Sexual Misconduct) which can be found on DND’s Information about Programs and Information Holdings (IPIH) page.

Under the Privacy Act, you have the right to access your personal information and request corrections to your personal information. Should you wish to exercise your rights under the Privacy Act, or have any questions about this privacy notice statement, contact DND’s Directorate of Access to Information and Privacy (DAIP) by submitting a Personal Information Request Form online, or send a written request to:

Directorate of Access to Information and Privacy (DAIP)
Department of National Defence
60 Moodie Drive
Ottawa, Ontario K1A 0K2

Should you wish to lodge a complaint with respect to the handling of your personal information, you may do so by contacting the Office of the Privacy Commissioner of Canada.