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RCMP OPERATIONAL STRESS INJURY (OSI)

1869 Upper Water Street
Suite PH 301, Pontac House
HALIFAX, NS B3J 1S9
www.wagners.co
Email: [email protected]

Please note: we will keep confidential any personal identifying information that you provide on this form, subject to first receiving permission from you.

Please complete this form if you wish to be kept informed of the progress of this case.

Completing this form creates no financial obligation for you. It does not create a lawyer/client relationship between yourself and Wagners (or any of its lawyers).

By completing this form you are asking Wagners to include you in our list of potential members in this class action, but our firm is not agreeing to represent your personal interests. Wagners will represent the interests of the class as a whole.

The definition of the class of people included in this class action may in the future change or be modified. We may not inform you or the public if and when the class definition changes.  It is your responsibility to ensure that your own personal interests and legal rights are being protected. You may wish to obtain independent legal advice in order to determine whether it would be in your best interest to pursue independent litigation in this matter. Should you meet the definition of a class member, you may be entitled to compensation if there is a final judgment or settlement in favour of the class. However, the class definition may change over time, and there is no guarantee of compensation regardless of the class definition.

RCMP OPERATIONAL STRESS INJURY (OSI)

CLASS ACTION INTAKE FORM

  • THIS FORM IS FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT A CLAIM FORM AND DOES NOT GUARANTEE ELIGIBILITY FOR ANY EVENTUAL COMPENSATION.

  • SECTION I: CONTACT INFORMATION

  • Claimant’s Name: Individual who was/is a member of the Royal Canadian Mounted Police:
  • Other names Claimant may be known as, if any (including maiden name, if applicable):
  • Claimant’s Mailing Address:
  • Email:
  • Home Phone:
  • Cell Phone:
  • Other Phone:
  • Facsimile:
  • Claimant’s Preferred Form of Contact:
  • Email:
  • Reg. Mail:
  • Phone:
  • Contact Person (If Other Than Claimant) and His/Her Contact Information:
  • Address (Mailing):
  • Email:
  • Home Phone:
  • Cell Phone:
  • Other Phone:
  • Facsimile:
  • Preferred form of contact:
  • Claimant’s Marital Status: (Please Circle)

  • SECTION II: EMPLOYMENT INFORMATION

  • Period of Service in the Royal Canadian Mounted Police:
  • Please complete the following in reverse chronological order, i.e. starting with your most recent posting:
  • *If there is not enough space, please provide this information on a separate and attached sheet.
  • History of Your Rank:
  • *If there is not enough space, please provide this information on a separate and attached sheet.
  • Have you suffered from, or been diagnosed with, an Operational Stress Injury (“OSI”)? (“Operational Stress Injury” or “OSI” means any persistent psychological difficulty that results from operational duties with the RCMP and causes impaired functioning, including but not limited to diagnosed medical conditions such as Post-Traumatic Stress Disorder, depression, anxiety, and panic attacks)

  • SECTION III: OTHER INFORMATION

  • 1. Please provide a detailed description of any mental health training you received while at RCMP Academy and while employed with the RCMP. This would include, but is not limited to, any preventative / proactive measures taken by the RCMP with respect to mental health:
  • *If there is not enough space, please provide this information on a separate and attached sheet.
  • 2. Please provide a detailed description of any discrimination, harassment or differential treatment experienced / witnessed as a result of suffering from, or being diagnosed with, an Occupational Stress Injury, including impacts, at all stages from aiming to secure a diagnosis, to treatment, to rehabilitation, to accommodation, to reintegration back into on-duty work:
  • *If there is not enough space, please provide this information on a separate and attached sheet.
  • 3. Please provide a detailed description of Mental Health Services received, including whether there were consistent debriefings after critical incidents, access to Mental Health Services for preventative purposes, whether you experienced issues accessing treatment (including due to posting location, accessibility, timing of services), whether you experienced issues obtaining a diagnosis, accommodation in employment as a result of your OSI, support from superiors / management, transfers to postings closer to OSI clinics and your experience with return-to-work protocols.
  • *If there is not enough space, please provide this information on a separate and attached sheet.
  • 4. Do you feel your career trajectory, opportunities for advancement, transfers, upward momentum etc. have been impacted because of your OSI? If so, please explain:
  • *If there is not enough space, please provide this information on a separate and attached sheet.
  • 5. Please provide a detailed description of any complaints you made regarding the above, including the date of the complaint(s) and any action taken in response to your complaint(s).

  • 6. Please provide any further information that you think may be relevant:
  • Thank you for completing this informational form. Upon receiving your contact information, we will add you to our database and will provide you with any relevant updates on the action. Please note that individual interviews and meetings are not required at this time.

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