# Part 1 -Privacy Complaint

Provide as much detail as possible about the complaint:

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| Type | PDF |
| Size | 128 KB |

[Open original PDF →](https://sam.hollandcollege.com/shared/QMS/Forms/QF151-200/QF176.pdf)

Referenced from: [Access to Information and Protection of Personal Information Policy](/pages/about/ai-and-ppi-html/)

## Document text

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## Part 1 -Privacy Complaint

- [ ]  Breach of personal privacy

- [ ]  Other

## Part 2 - Complainant's Information

Family Name *

First and middle name(s) *

Unit/Apt.no

Street no. *

Street name *

PO Box

City *

Province *

Postal Code *

Home phone no.

Work phone no.

Cell phone no.

E-mail address

## Part 3 - Description of the Complaint

Provide as much detail as possible about the complaint:

a)  Date or time period \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (yyyy/mm/dd) to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (yyyy/mm/dd ) *

- b)  Faculty, service, or department involved): *

- c)  Persons Involved: *

- d) Description: *

## Part 4 - Expected Outcome

Briefly describe your expectations as to the outcome of the complaint:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature

Date (yyyy/mm/dd)

## * REQUIRED FIELD

## PLEASE SEND YOUR COMPLETED FORM TO THE ADDRESS ABOVE.  THANK YOU.

The personal information requested on this form is collected under the authority of Section 31(c) of the PEI Freedom of Information and Protection of Privacy Act.  It will be used for the purpose of responding to and investigating privacy complaints. Quest ions about the collection or use of this information should be directed to Holland College's Chief Privacy Officer at privacy@hollandcollege.com or 902-566-9542, 140 Weymouth Street, Charlottetown, PE, C1A 4Z1.

Office of the Chief Privacy Officer 140 Weymouth St. Charlottetown, PE   C1A 4Z1

## Privacy Complaint Form

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<small>Source: [https://sam.hollandcollege.com/shared/QMS/Forms/QF151-200/QF176.pdf](https://sam.hollandcollege.com/shared/QMS/Forms/QF151-200/QF176.pdf)</small>