Treasury Board of Canada Secretariat forms

It is important to first determine which government institution is most likely to have the information you are seeking.

Refer to Information About Programs and Information Holdings for a description of personal information held by the institution or
Contact the Access to Information and Privacy (ATIP) Coordinator of the institution.

Make an online request

Use the ATIP Online Request Portal, for a faster, easier and more convenient way to submit access to information or privacy requests. Apply online today to certain government institutions to save time and postage.

Mail a request

If you are unable to use the ATIP Online Request Portal, you may request information using the Access to Information Request Form (TBC/CTC 350-57) (available in PDF or HTML formats), or send a letter clearly explaining what records you are seeking, to the ATIP Coordinator of the government institution holding the information.

Available formats

Access to information request form
( PDF , 271 KB )

An HTML version of the Access to Information Request Form (TBC/CTC 350-57) is also available for accessibility purposes.

Personal Information Request Form
(TBC/CTC 350-58)

Title	Personal Information Request Form
Number	(TBC/CTC 350-58)
Category	Access to Information and Privacy

Which government institution holds my information?

It is important to first determine which government institution is most likely to have the information you are seeking.

Refer to Information About Programs and Information Holdings for a description of personal information held by the institution or
Contact the Access to Information and Privacy (ATIP) Coordinator of the institution.

Make an online request

Mail a request

Available formats

Personal information request form
( PDF , 218.8 KB )

An HTML version of the Personal information request form (TBC/CTC 350-58) is also available for accessibility purposes.

Consent for a Personal Information Request Form
(TBC/CTC 350-60E)

Title	Consent for a Personal Information Request Form
Number	(TBC/CTC 350-60E)
Category	Access to Information and Privacy

Available formats

Consent for a Personal Information Request Form
( PDF , 148 KB )

An HTML version of the Consent for a Personal Information Request Form (TBC/CTC 350-60E) is also available for accessibility purposes.

Authorizing a Personal Information Request to be Made on Your Behalf Form
(TBC/CTC 350-55E)

Title	Authorizing a Personal Information Request to be Made on Your Behalf Form
Number	(TBC/CTC 350-55E)
Category	Access to Information and Privacy

Available formats

Authorizing a Personal Information Request to be Made on Your Behalf Form
( PDF , 150 KB )

An HTML version of the Authorizing a Personal Information Request to be Made on Your Behalf Form (TBC/CTC 350-55E) is also available for accessibility purposes.

Access to Information Tracking Document
(TBC/CTC 350-59)

Title	Access to Information Tracking Document
Number	(TBC/CTC 350-59)
Category	Access to Information and Privacy

Available formats

Access to Information Tracking Document
( PDF , 102 KB )

An HTML version of the Access to Information Tracking Document (TBC/CTC 350-59) is also available for accessibility purposes.

Record Correction Request Form
(TBS/SCT 350-11)

Title	Record Correction Request Form
Number	(TBS/SCT 350-11)
Category	Access to Information and Privacy

Available formats

Record Correction Request Form
( PDF , 157.9 KB )

An HTML version of the Record Correction Request Form (TBC/CTC 350-11) is also available for accessibility purposes.

Report on the Access to Information Act
(TBS/SCT 350-62)

Title	Form for the Statistical Report on the Access to Information Act
Number	(TBS/SCT 350-62)
Category	Access to Information and Privacy

Instructions

Institutions must submit statistical reports annually to the Information and Privacy Policy Division on activities relating to the administration of the Access to Information Act that take place in their institutions.

Reports submitted must be created in XML or XLS formats; however an HTML version is available here to illustrate the data elements that are required in the report.

Available formats

An HTML version of the Form for the Statistical Report on the Access to Information Act (TBC/CTC 350-62) is also available for accessibility purposes.

Report on the Privacy Act
(TBS/SCT 350-63)

Title	Form for the Statistical Report on the Privacy Act
Number	(TBS/SCT 350-63)
Category	Access to Information and Privacy

Instructions

Institutions must submit statistical reports annually to the Information and Privacy Policy Division on activities relating to the administration of the Privacy Act that take place in their institutions.

Reports submitted must be created in XML or XLS formats; however an HTML version is available here to illustrate the data elements that are required in the report.

Available formats

An HTML version of the Form for the Statistical Report on the Privacy Act (TBC/CTC 350-63) is also available for accessibility purposes.

Privacy Act Material Breach Report Form
(TBS/SCT 350-64E)

Title	Privacy Act Material Breach Report Form
Number	(TBS/SCT 350-64E)
Category	Access to Information and Privacy

Reporting Material Privacy Breaches to the OPC and TBS

This form is for use by Government of Canada Institutions to report material privacy breaches to the Office of the Privacy Commissioner (OPC) and the Treasury Board of Canada Secretariat (TBS). The OPC Material Breach Reporting Portal (under development) may also be used to report material privacy breaches to the OPC and TBS.

As of March 1st, 2024, Government of Canada institutions must use either the OPC Material Breach Reporting Portal or the TBS Privacy Act Material Breach Report Form to report material privacy breaches to the OPC and TBS.

Available formats

For best results, download and open this form in Adobe Acrobat, Foxit PDF Editor, or Kofax Power PDF and enable JavaScript for this document. Trying to edit this form before saving it locally and enabling java script will result in important form functions being unavailable.

Do not edit the form within Microsoft Edge, Google Chrome, Apple Safari, Mozilla Firefox or other browsers.

Privacy Act Material Breach Report Form
( PDF , 930 KB )

Phoenix pay system

Claim out-of-pocket expenses
If you incurred expenses such as interest charges or late fees because of Phoenix, you can submit a claim.
Claims for impacts on income taxes and government benefits
If you were owed salary from one year that was only paid the following year, you might pay too much income tax or receive reduced government benefits and credits, such as the Canada child benefit.
Request an advance for government benefits
If your government benefits, such as the Canada child benefit, or other credits were reduced because you were overpaid by Phoenix, you can request an advance to help you during this time.
Reimbursement for tax advice
Find out if you are eligible for reimbursement of expenses related to tax advice.
Claim compensation for severe impacts
If you experienced severe personal or financial hardships, such as financial costs, lost investment income, or impacts to your career or well-being, you can submit a claim.
Claim general compensation for damages related to Phoenix
Former employees can claim financial compensation equivalent to leave through the 2019 Phoenix pay system damages agreement.

Disability Insurance

Disability insurance claim forms

The Disability Insurance Plan claim forms can be found on the Sun Life DI webpage: www.sunlife.ca/DI.

Employee’s Statement (490L-M-12500-E)
Attending Physician’s Questionnaire (490L-P-12500-GEN-E, 490L-P-12500-MHC-E, or 490L-P-12500-MSK-E)
Employer’s Statement (Immediate Supervisor or Manager)(4841-E)
Employer’s Statement (Compensation Advisor)(4811-E)

Leave

Application for Leave with Income Averaging
(TBS/SCT 325-10)

Title	Application for Leave with Income Averaging
Number	(TBS/SCT 325-10)
Category	Leave

Available formats

Application for Leave with Income Averaging
( PDF , 25 KB )

An HTML version of the Application for Leave with Income Averaging (TBC/CTC 325-10) is also available for accessibility purposes.

Application for Pre-retirement Transition Leave
(TBS/SCT 325-9)

Title	Application for Pre-retirement Transition Leave
Number	(TBS/SCT 325-9)
Category	Leave

Available formats

Application for Pre-retirement Transition Leave
( PDF , 33 KB )

An HTML version of the Application for Pre-retirement Transition Leave (TBC/CTC 325-9) is also available for accessibility purposes.

Dental Care

Public Service Dental Care Plan - Claim form
(The Canada Life Assurance Company)
Public Service Dental Care Plan - Authorization for Claims Submission and Redirection of Payment
(The Canada Life Assurance Company)

Pensioners’ Dental Services Plan (PDSP) Claim Form (PDF Document – 54 KB)
(Sun Life Financial)
Some PDSP forms were made obsolete as of April 1 st 2006 . For more information on PDSP enrolment and eligibility, see the PDSP menu.

Title	Pensioners’ Dental Services Plan - Authorization for Claims Submission and Re-direction of Payment
Number	(Inventory Number 00093-E-3-05)
Category	Pensioners’ Dental Services Plan

Available formats

Authorization for Claims Submission and Re-direction of Payment
( PDF , 185 KB )

An HTML version of the Authorization for Claims Submission and Re-direction of Payment (Inventory Number 00093-E-3-05) is also available for accessibility purposes.

Public Service Health Care Plan

PSHCP Claim Form (PDF Document – 614 KB)
(Public Service Health Care Administration Authority Web Site)
PSHCP Claim Form-Out-of-Country claims (Comprehensive Coverage) (PDF Document – 655 KB)
(Public Service Health Care Administration Authority Web Site)

Public Service Management Insurance Plan

Claim Forms for Long-Term Disability

Forms to be completed and sent to iA Financial Group

Employee’s Statement (F54-1011A-57)
Attending Physician’s Questionnaire (F54-1014A-57 for a mental health condition), or (F54-1015A-57 for a musculoskeletal condition), or (F54-1016A-57 for all other medical conditions)
Employer’s Statement (F54-1012A-57 immediate supervisor or manager)
Employer’s Statement (F54-1013A-57 departmental compensation/Human Resources advisor)

Title	Claim for Accidental Dismemberment Benefit
Number	(TBS/SCT 5954, 5955)
Category	Public Service Management Insurance Plan

Available formats

Claim for Accidental Dismemberment Benefit
( PDF , 229 KB )

An HTML version of the Claim for Accidental Dismemberment Benefit (TBC/CTC 5954, 5955) is also available for accessibility purposes.

Claim Form for Death Benefit
(TBS/SCT 5948, 5949)

Title	Claim for Death Benefit
Number	(TBS/SCT 5948, 5949)
Category	Public Service Management Insurance Plan

Available formats

Claim for Death Benefit
( PDF , 148 KB )

An HTML version of the Claim for Death Benefit (TBC/CTC 5948, 5949) is also available for accessibility purposes.

Security

Security in Contracting

Security Requirements Check List (SRCL)
(TBS/SCT 350-103)

Title	Security Requirements Check List (SRCL)
Number	(TBS/SCT 350-103)
Category	Security in Contracting

Requirement for completion

In accordance with Section 10.4 of the Security Policy for the Government of Canada, contracting authorities must:

Ensure security screening of private sector organizations and individuals who have access to protected and classified information and assets, as specified in the standards.
Ensure safeguarding of government assets, including IT systems.
Specify the necessary security requirements in terms and conditions in any contractual documentation.

Available formats

Security Requirements Check List (SRCL)
( PDF , 396 KB )

An HTML version of the Security Requirements Check List (TBC/CTC 350-103) is also available for accessibility purposes.

Security Screening

Security Screening Application and Consent Form
Notification of Change in Security Clearance
(CSIS/SCRS 4160e) (Canadian Security Intelligence Service Web Site)

Title	Security Screening Certificate and Briefing Form
Number	(TBS/SCT 330-47)
Category	Security Screening

Requirement for completion

In accordance with the Security Policy for the Government of Canada, both the requirement for and the processing of a personnel security screening action must be based on a specified need. As such, please do not initiate the completion of this or any other security screening form unless this need has been identified by the federal government department/agency that requested you to complete them.

For security reasons and to ensure that your own privacy rights are being safeguarded, security forms available on our Treasury Board Secretariat web-site cannot be electronically sent. As such, please print and mail or hand carry completed forms to the federal government department/agency that requested you complete them.

Available formats

Security Screening Certificate and Briefing Form
( PDF , 21 KB )

An HTML version of the Security Screening Certificate and Briefing Form (TBC/CTC 330-47) is also available for accessibility purposes.

Personnel Screening, Consent and Authorization Form
(TBS/SCT 330-23e) Archived

Archived information

Archived information is provided for reference, research or recordkeeping purposes. It is not subject à to the Government of Canada Web Standards and has not been altered or updated since it was archived. Please contact us to request a format other than those available.

Title	Personnel Security Screening Form
Number	(TBS/SCT 330-23)
Category	Security Screening

Instructions prior to completing the form

In accordance with the Policy on Government Security, both the requirement for and the processing of a personnel security screening action must be based on a specified need. As such, please do not initiate the completion of this or any other security screening form unless this need has been identified by the federal government department/agency that requested you to complete them.

For security reasons and to ensure that your own privacy rights are being safeguarded, this security form cannot be sent electronically. It must be printed and mailed or submitted by hand directly to the federal government department/agency that requested you complete it.

Please pay special attention to obtain both the information required and carefully read the instructions provided. If necessary, please contact your Human Resources contact or security office for specifics.