Skip to content | Skip to institutional links

Common menu bar links

Institutional links

Back to
- Public Involvement and Partnerships
Explore...
Transparency

Completed Access to Information Requests

Proactive Disclosure

Food and Nutrition

Print |

Need Larger Text? |

Voluntary Statement of Information Form for the Public Consultation on Dietary Sodium Reduction

Warning This content was archived on June 24, 2013.

Archived Content

Information identified as archived on the Web is for reference, research or recordkeeping purposes. It has not been altered or updated after the date of archiving. Web pages that are archived on the Web are not subject to the Government of Canada Web Standards. As per the Communications Policy of the Government of Canada, you can request alternate formats on the "Contact Us" page.

The online consultation is now closed. The content found on this page is a snapshot of the live consultation as it was presented to the public and contains the content that was open for submissions during the consultation period.

The Health Products and Food Branch (the Branch) of Health Canada and its stakeholders recognize the importance and value of openness and transparency in public involvement activities and decision-making processes. The Branch's commitment to transparency is supported in its Public Involvement Framework and in its Strategic Plan 2007-2012 under Strategy 5.

The Branch encourages the participation of diverse voices and promotes the inclusion of a broad range of views in its public involvement activities. The Branch provides participants of public involvement activities the opportunity to complete all or part of the attached Participant Voluntary Information Form (the Form).

Participants are not obliged to complete any part of the Form nor to consent to its use by the Branch. The decision by participants to complete, or to decline to complete and sign, all or part of the Form is voluntary. Neither the participant's decision nor the information, if any, that is provided, will be used by the Branch to limit the participant's attendance or expression of opinions in the public involvement activity. The information provided by participants is limited to that which is directly related to the subject of the public involvement activity only.

The Branch uses information voluntarily provided by participants in the Form to prepare a Participant Voluntary Information Summary (the Summary). In support of creating a transparent process, the Summary is distributed by Branch officials to all of the participants in this public involvement activity. The Summary will also be appended to any reports or documents resulting from this public involvement activity and will be available on the Branch's website. The Branch will not make use of the information provided in the Form or the Summary for any other purpose.

Should you wish to complete all or any part of the attached Participant Voluntary Information Form, please submit the completed and signed form when registering for this public involvement activity.

Office of Consumer and Public Involvement
Health Products and Food Branch
Health Canada
January 2008

Voluntary Statement of Information Form

Purpose for Collection of Personal Information

The purpose for the Health Product and Food Branch's (the Branch) collection of personal information contained in this Form is to enhance transparency in its public involvement activities and decision making processes. The Branch will use information provided in the Form to prepare a Participant Voluntary Information Summary based on information voluntarily provided by participants who complete all or part of the Form. In support of creating a transparent process, the Summary will be distributed by Branch officials to all of the participants in this public involvement activity. The Summary will also be appended to any reports or documents resulting from this public involvement activity and will be available on the Branch's Web site. The Branch will not make use of the information provided in the Form or the Summary for any other purpose. The Branch will not use or disclose the information provided in the Form if consent has not been provided by the participant.

Consent and Acknowledgment to Use Personal Information:

I consent to the Branch's use of the information, including personal information, provided by me in this Form:

I understand and acknowledge that completion of all or part of this Form is voluntary and that I am not required, for the purposes of participation in this public involvement activity, by the Branch to complete all or any part of this Form.
I understand and acknowledge that my consent to the Branch's use of the information, including personal information, in its public reports and/or distribution of the information to participants of this public involvement activity means that the information may be directly or indirectly available to, and used by, the public.

Please select one of the following:

	Yes, HPFB can use and disclose the information I provide in this form, for the purposes stated above.
	I decline to provide any further information. HPFB can use and disclose only my name and the name of the organization I represent (where applicable), for the purposes stated above. This will be reflected in the Summary.
	I decline to provide any further information, and do not consent to have my name disclosed for the purposes stated above.

Name

Date

A. Name

1. Name of participant:

2. Are you listed in the Public Registry of Lobbyists?

yes no

3. I am participating in this public involvement activity: (Please check one)

as an individual (see Sections B, D, E)
on behalf of an organization (see Sections C, D, E)

B. Individuals

1. For the purposes of this public involvement activity, I identify myself as a/an: (Check all that are applicable).

	Academic/researcher
	Health professional
	Industry
	Patient
	Consumer
	General public
	Volunteer
	Other (specify)

C. Organizations

1. Name of organization represented:

2. The scope of my organization's membership is:

	International
	National
	Provincial/Territorial
	Local
	Other (specify)

3. For the purposes of this public involvement activity, the type of organization that I am representing is: (Check all that are applicable).

	Academic/research community
	Association
	Coalition
	Community or consumer (e.g. seniors, youth, immigrants, multi-faith, linguistic)
	Patient
	Voluntary
	Government
	Industry
	Other (specify)

4. Mandate of organization (Maximum 500 characters)

5. Does the organization you represent have funding guidelines and/or sponsorship agreements to deal with issues pertaining to funding or contributions?

yes no

D. Statement of Interests and Affiliations - for individuals and organizations

In this section, you are asked to provide information about your financial and non-financial interests and affiliations of relevance to the objectives of this public involvement activity only.

1. Direct financial interests

Do you, your spouse, and/or dependent minor child currently hold any of the following direct financial interests with an organization or company likely to be affected by the outcome of this public involvement activity? Please check all that apply, and include the name of the organization or company with which the interest is held, and monetary range. There is no need to identify household member.

Type of direct financial interest	Name of organization or company	Value
Employment yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up
Investments in companies yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up
Partnerships yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up
Equity yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up
Royalties yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up
Joint ventures yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up
Trusts yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up
Real property, stocks, shares, or bonds yes no		$0 - $5,000 $5,000- $25,000 $25,000 and up

2. Indirect financial interests

In the past year, have you, or your organization, received any of the following from an organization or company likely to be affected by the outcome of this public involvement activity, other than your present employer? Please check all that apply, and, where applicable, include: whether the payment or support was received by you, your organization, or both; the name of the organization or company who provided the support; and the monetary range.

Type of payment or support	Name of organization or company	Received by?	Value
Payment for work done or being done, including past employment, contracts and consulting yes no		You Your organization You and your organization	$0 - $5,000 $5,000- $25,000 $25,000 and up
Research support yes no		You Your organization You and your organization	$0 - $5,000 $5,000- $25,000 $25,000 and up
Personal education grants yes no		You Your organization You and your organization	$0 - $5,000 $5,000- $25,000 $25,000 and up
Contributions yes no		You Your organization You and your organization	$0 - $5,000 $5,000- $25,000 $25,000 and up
Fellowships yes no		You Your organization You and your organization	$0 - $5,000 $5,000- $25,000 $25,000 and up
Sponsorships, or honoraria e.g. to participate in speaking or writing activities yes no		You Your organization You and your organization	$0 - $5,000 $5,000- $25,000 $25,000 and up
Travel, meals or accommodation to attend this public involvement activity? yes no

Intellectual interests

3. In the past year, have you provided formal advice or opinion to industry, a government organization (international, foreign, Canadian federal, provincial or municipal) or a non-government organization (for instance by participating on an advisory body) on issues of relevance to the topic under consideration?

yes no

Please indicate the date, the subject on which you provided the advice or opinion, and who you provided it to.

Date (month, year)	Subject (e.g. topic or name of advisory body)	Name of organization or company	Voluntary or Paid?
			Volunteer Paid
			Volunteer Paid
			Volunteer Paid
			Volunteer Paid
			Volunteer Paid
			Volunteer Paid

4. Have you or your organization made public a statement (including speeches, lobbying, etc.) or a point of view (including in papers, articles, journals, or other publications) on issues of relevance to the topic under consideration at this public involvement activity?

yes no

If yes, please list the top three most relevant (in your opinion), and indicate the date and title of the statement or speech, and publication or venue as applicable.

Date (month, year)	Title	Publication or venue

5. Do you or your organization have any of the following professional or volunteer affiliations with an organization with an interest in, or likely to be affected by, the outcome of this public involvement activity?

Please check all that apply, and indicate the name of the organization or company.

Type of affiliation	Name of organization or company
Membership of professional societies yes no
Membership of trade or industry associations yes no
Membership of public interest, community or advocacy groups yes no	Member Board member

E. Participation at Health Canada

1. In the past year, have you or your organization received a grant or contribution from Health Canada?

yes no

If yes, please indicate the date, project title, and the relevant Branch of Health Canada.

Date	Project Title	Branch of Health Canada
		Communications, Marketing and Consultations Directorate First Nations and Inuit Health Branch Health Policy Branch Health Products and Food Branch Healthy Environments and Consumer Safety Branch Public Health Agency of Canada Other (please specify)
		Communications, Marketing and Consultations Directorate First Nations and Inuit Health Branch Health Policy Branch Health Products and Food Branch Healthy Environments and Consumer Safety Branch Public Health Agency of Canada Other (please specify)
		Communications, Marketing and Consultations Directorate First Nations and Inuit Health Branch Health Policy Branch Health Products and Food Branch Healthy Environments and Consumer Safety Branch Public Health Agency of Canada Other (please specify)

2. In the past year, have you or your organization participated in any other Health Canada public involvement activities, such as workshops, focus groups, roundtables, electronic consultations, public forums, or bilateral meetings?

yes no

If yes, please indicate the date, title or topic of the public involvement activity, and the relevant Branch of Health Canada.

Date	Title/ Topic of Public involvement Activity	Branch of Health Canada
		Communications, Marketing and Consultations Directorate First Nations and Inuit Health Branch Health Policy Branch Health Products and Food Branch Healthy Environments and Consumer Safety Branch Public Health Agency of Canada Other (please specify)
		Communications, Marketing and Consultations Directorate First Nations and Inuit Health Branch Health Policy Branch Health Products and Food Branch Healthy Environments and Consumer Safety Branch Public Health Agency of Canada Other (please specify)
		Communications, Marketing and Consultations Directorate First Nations and Inuit Health Branch Health Policy Branch Health Products and Food Branch Healthy Environments and Consumer Safety Branch Public Health Agency of Canada Other (please specify)

Common menu bar links

Institutional links

Back to

Explore...

Transparency

Voluntary Statement of Information Form for the Public Consultation on Dietary Sodium Reduction

Archived Content

Voluntary Statement of Information Form

A. Name

B. Individuals

C. Organizations

D. Statement of Interests and Affiliations - for individuals and organizations

E. Participation at Health Canada