# Policy - Records, Privacy and Health Information

> Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-POL-21.
>
> Canonical: https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information
>
> Licence: CC BY-NC-SA 4.0 with the Adopting Agency Grant (https://creativecommons.org/licenses/by-nc-sa/4.0/)
>
> General information only, not legal, medical or other professional advice. Verify every requirement against the current official text of the law, standards and manufacturer instructions that apply to you. Obtain your own legal review and consult your joint health and safety committee before adopting anything. You adopt, adapt, implement and rely on this material entirely at your own risk and on your own responsibility. Full terms: Terms of Use, thehumanfactor.ca.

> **Warning: Adoption without implementation increases legal exposure**
>
> Adopting this policy without the training, equipment, supervision, verification and resources to carry it out as written increases municipal and command liability in a regulatory investigation or a fatality inquiry. See [00a Copyright, Licence and Legal Notices](https://thehumanfactor.ca/library/fire-service-safety/copyright-licence-and-legal-notices).

> **Warning: Review before adoption**
>
> This model policy needs review by the department’s counsel and the municipality’s privacy and records officers, and against every applicable collective agreement. Privacy and access law differs by province and by whether the department is a municipal division, a society or a provincial body. It is general information, not legal advice. Where it conflicts with a statute, regulation or agreement, the statute, regulation or agreement governs. Section numbers are cited as of 2026-10-22; confirm each one before signing.

## How to use this model

**Format.** Adopt as a department policy that sits under the municipality’s records management and privacy policies and adds what the safety management system needs. Where the municipality’s retention schedule is shorter than this policy for a safety record, this policy’s period applies as the department’s own standard.

**Drafting conventions.** **Shall** means mandatory. **Should** means expected unless a documented reason exists. **May** means permitted. Placeholders in double curly braces, such as `{{Department}}`, are completed by the department. Drafting notes sit in callouts and are removed before adoption.

**Keep intact.** Medical records with the provider and clearance status only to the department (5.3), exposure record retention (5.4), the learning firewall for records (5.6), members’ access to their own records (5.7), and the four house principles. **Adapt.** Record custodians and system names; retention periods where the law of your province or territory sets longer ones ([J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention)).

| Field | Entry |
|:---|:---|
| Policy title | Records, Privacy and Health Information Policy |
| Policy number | FSSMS-POL-21 ({{Department}} number: {{Policy number}}) |
| Approved by | {{Fire Chief}} |
| Effective date | {{Effective date}} |
| Next review date | {{Review date}} (12 months after adoption, then every three years) |
| Policy owner | {{Division Chief, Safety}} |
| Consulted | {{JOHSC}}; {{Union}}; {{Volunteer Association}}; municipal records manager and privacy officer; department physician or occupational health provider; counsel |

## 1. Purpose

1.1 To say what records the safety management system creates, who holds each, for how long, who may see it, and how the department keeps health information, learning information and personnel information apart.

1.2 To meet any records and statistics element the applicable OHS statute requires in the written OHS program ([J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program); [J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention)), the documented information requirements of the management-system standard (ISO 45001:2018, cl. 7.5), the exposure record expectations of the fire service standards [(NFPA 1550, 2024, ch. 15 and 16)](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-nfpa-1550), and the accreditation criterion on exposure records [(CPSE, 2019, criterion 11A.10)](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-cpse-2019), while complying with the privacy and access law that applies to the department ([J10 Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/j10-privacy-and-health-information)).

## 2. Scope and application

2.1 Applies to every record created, received or held under the safety management system, in any form, by any member, program, team, committee, provider or contractor acting for the department.

2.2 Applies to the occupational health provider, the employee and family assistance provider, the peer support team and any clinician under contract, to the extent the information-sharing protocol in 5.3 governs what passes between them and the department.

2.3 Does not displace the municipality’s records management by-law or policy, the compensation board’s reporting rules, or a collective agreement’s provisions on personnel files; it adds the safety-specific rules.

## 3. Definitions

**Clearance status.** The only medical information the department holds about a member: fit for duty, fit with stated restrictions, or unfit, with the date and the next evaluation date.

**Custodian.** The role or body that holds a record and controls access to it.

**Exposure record.** The per-member, per-event record of exposure to products of combustion, chemicals, biological agents, noise, heat or other hazards, and of potentially traumatic events, with the fields in [Form - Exposure Report](https://thehumanfactor.ca/library/fire-service-safety/form-exposure-report).

**Health information.** Information about a member’s physical or mental health, diagnosis, treatment or test results. Held by the provider, never by the department, except clearance status.

**Learning record.** Any record produced for the purpose of learning under [Incident Investigation and Learning Program](https://thehumanfactor.ca/library/fire-service-safety/incident-investigation-and-learning-program): debrief notes, after-action reviews, learning-team write-ups, post-incident analysis working papers and interview notes, near-miss and good-catch reports, independent learning review working papers.

**Personal information.** Recorded information about an identifiable individual.

**Personnel record.** The member’s employment or membership file held by human resources or the department: appointment, training and certification, discipline, performance.

**Retention period.** The minimum time a record is kept before it may be destroyed under the department’s schedule.

**Safety record.** Any record the safety management system creates that is not a health, learning or personnel record: policies, procedures, inspections, test and maintenance records, training records, investigation reports, JOHSC minutes, audit reports, the registers.

## 4. Principles

1.  **People are the solution we build around, not the problem to fix.** Records exist to protect members: to prove a claim, to show an exposure history, to show training was given. The member is the first beneficiary.

2.  **Procedures describe work as done, written with the people who do it.** Reporting forms are short, available on paper and by phone, and designed with the members who complete them.

3.  **Learning comes before blame, and learning information is never used for discipline.** Learning records live apart from personnel records, with different custodians and access.

4.  **Psychological safety is a condition of safety, so speaking up is expected and protected.** A member who reports knows where the report goes, who sees it, and that it will not appear in their file.

5.  **Collect the minimum; keep what protects.** The department collects only what it needs, and keeps exposure and training records for as long as a claim could arise.

6.  **Write for disclosure.** Every record is written as if it will be read under freedom-of-information law, by the member, by the regulator, by a court. Roles, not names, where the purpose allows; facts, not opinion about people.

7.  **Health information belongs to the member and the clinician.** The department asks only whether the member can do the job.

## 5. Policy statements

### 5.1 Records the system creates, and their custodians

5.1.1 The department shall maintain the records in the table below, each with a named custodian, a system of record, an access list and a retention period, entered in [05 Document Control and Records](https://thehumanfactor.ca/library/fire-service-safety/document-control-and-records). Accountable: {{Division Chief, Safety}}.

| Record family | Examples | Custodian (role) | System | Retention (minimum) |
|:---|:---|:---|:---|:---|
| Policies, programs, procedures and their versions | This policy set; program modules; SWPs; consultation records | {{Division Chief, Safety}} | {{Records system}} | Life of the document plus 10 years; every version retained |
| JOHSC records | Minutes, recommendations and responses, inspection reports, terms of reference | JOHSC co-chairs | {{Records system}} | Minutes and recommendations 10 years, or longer where the applicable law sets a longer period ([J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative); [J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention)) |
| Inspection, test and maintenance records | Station inspections; SCBA flow tests; fit tests; breathing air tests; gear advanced inspections; ladder and aerial tests; apparatus tests; cylinder requalification | Program managers | {{Records system}}; equipment records | Life of the equipment plus five years; fit test records for the member’s service plus 30 years as part of the exposure history |
| Training and competency records | Orientation; course completion; certifications; competency sign-offs; supervisor competency; JOHSC training | Training division | Learning management system | Member’s service plus 30 years |
| Participation records (volunteers) | Calls and training attended per year; chief’s annual confirmation | {{Deputy Chief}} | Attendance system | Member’s service plus 30 years |
| Injury, illness and incident reports | Incident and injury forms; supervisor’s reports; regulator and board notices | {{Health and Safety Officer}} | Incident reporting system | Member’s service plus 30 years for injury and illness; never less than any statutory period for the others ([J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention)) |
| Exposure records | Fireground, chemical, biological, noise, heat and potentially traumatic event exposures | {{Health and Safety Officer}} | Exposure tracking system | Member’s service plus 30 years (5.4) |
| Investigation reports (formal) | Statutory investigation reports with causes and corrective actions | {{Division Chief, Safety}} | {{Records system}} | 30 years |
| Learning records | Debrief and AAR notes; learning-team write-ups; PIA and ILR working papers; near-miss and good-catch reports | {{Division Chief, Safety}} (learning custodian) | {{Learning system}}, separate from personnel and incident systems | Working papers and interview notes: destroyed on closure of the review unless counsel directs otherwise; final learning reports and de-identified near-miss data: 10 years |
| Health information | Medical evaluation results, test results, diagnoses, treatment, fitness assessment detail | Occupational health provider (clinician) | Provider’s clinical record | Per the provider’s professional and statutory obligations; the department holds none |
| Clearance status | Fit, fit with restrictions, unfit; date; next due | {{Health and Safety Officer}} | Medical clearance tracker | Member’s service plus 30 years |
| Peer support contact records | Minimal contact log without content | Peer support team lead | Outside human resources and department systems | Aggregate only reported; contact log destroyed after {{Peer support log retention}} (default two years) |
| Risk register, Corrective Action Register, audit reports, management review minutes, indicators |  | {{Division Chief, Safety}} | {{Records system}} | Life of the program; audit reports 10 years |
| Personnel records | Appointment, performance, discipline, conduct process records | Human resources | Human resources system | Per the municipality’s schedule and the collective agreement |

5.1.2 No record family shall be held in a system that lets a person with access to one family read another without authorization; in particular, learning records, health information and personnel records are in separate systems or separate access-controlled areas. Accountable: {{Division Chief, Safety}}; information technology.

### 5.2 Custody and access

5.2.1 Each custodian shall keep an access list by role, review it annually, and log disclosures outside the list. Accountable: each custodian.

5.2.2 Access to injury, exposure and clearance records is limited to the health and safety officer, the senior officer responsible for health and safety, the member’s officer for the member’s own current restrictions, the occupational health provider, and human resources for compensation claims. Accountable: {{Health and Safety Officer}}.

5.2.3 The JOHSC receives aggregate injury, exposure and near-miss data, and may see an individual incident report with identifying details removed, except where a committee member is participating in an investigation under the statute, in which case the committee member sees what the investigation requires and is bound by confidentiality ([J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative)). Accountable: {{Division Chief, Safety}}.

5.2.4 The regulator and the compensation board receive what the statute requires ([J08 Incident Reporting and Investigation](https://thehumanfactor.ca/library/fire-service-safety/j08-incident-reporting-and-investigation)), through the senior officer responsible for health and safety, with a log of what was sent. Accountable: {{Division Chief, Safety}}.

### 5.3 Medical records and the information-sharing protocol

5.3.1 Health information shall be held by the occupational health provider as custodian under the health privacy statute that governs clinicians ([J10 Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/j10-privacy-and-health-information)). The department shall receive only clearance status: fit, fit with stated restrictions, or unfit, with dates ([NFPA 1580, 2025](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-nfpa-1580); CSA Z94.4-18). Accountable: {{Division Chief, Safety}}; the provider.

5.3.2 The department shall have a written information-sharing protocol with the provider, the employee and family assistance provider and the peer support program that names what crosses the line and when: clearance status; restrictions the officer needs to assign duties safely; imminent risk to the member or others; and the member’s own consent for anything else. Accountable: {{Division Chief, Safety}}.

5.3.3 No medical result, diagnosis, test, questionnaire or fitness assessment detail shall be placed in a personnel file or any department system. Where a department has such material from before this policy, it shall be transferred to the provider or destroyed with the member’s knowledge, on counsel’s advice. Accountable: {{Division Chief, Safety}}; human resources.

5.3.4 A member’s restriction shall be communicated to the member’s officer as a duty restriction (for example “no SCBA work until further notice”), never as a condition. Accountable: {{Health and Safety Officer}}.

5.3.5 Return-to-work and accommodation planning uses functional abilities information from the provider, not diagnosis, under the municipality’s process, any return-to-work cooperation duty in the applicable workers’ compensation law ([J33 Return to Work, Accommodation and Hours of Work](https://thehumanfactor.ca/library/fire-service-safety/j33-return-to-work-accommodation-and-hours-of-work)), and the work disability management model (CSA Z1011:20). Accountable: human resources.

### 5.4 Exposure records

5.4.1 The department shall keep an exposure record per member per event, with the fields in [Form - Exposure Report](https://thehumanfactor.ca/library/fire-service-safety/form-exposure-report), exportable per member for the lifetime of the record, and shall retain it for the member’s service plus 30 years. No Canadian jurisdiction was found to set a fire service exposure record retention period ([J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention)); the 30-year period is adopted from the established United States occupational exposure record rule as the department’s own standard (OSHA, n.d.-a, 29 C.F.R. § 1910.1020); confirm against any provincial or territorial schedule and record the basis. Accountable: {{Health and Safety Officer}}.

5.4.2 Potentially traumatic event exposures shall be recorded by the member on a personal exposure report under the same retention and access rules, with content limited to the event, date and role, not to the member’s reaction [(NFPA 1550, 2024, ch. 15)](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-nfpa-1550). Accountable: {{Health and Safety Officer}}.

5.4.3 Each member shall be able to obtain their full exposure history within ten working days of asking, and shall receive it on leaving the department. Accountable: {{Health and Safety Officer}}.

5.4.4 Exposure records shall be designed so they can be mapped to a provincial or national firefighter exposure registry if one is established. Accountable: {{Division Chief, Safety}}.

### 5.5 Retention and destruction

5.5.1 The retention periods in 5.1.1 are minimums. The applicable law may set a default retention period for the records its regulations require, or periods for particular records only ([J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention)); where a statutory period is longer than the period in 5.1.1, the statutory period applies, and the department’s periods exceed the statutory ones wherever a claim could arise later. Accountable: {{Division Chief, Safety}}.

5.5.2 No safety, exposure, training, participation or clearance record shall be destroyed while a claim, complaint, investigation, inquest, prosecution or access request involving it is open or reasonably foreseeable. Accountable: each custodian.

5.5.3 Destruction shall be by a method appropriate to the sensitivity, logged with the record series, date range and authority. Accountable: each custodian.

5.5.4 On a member’s departure, the department shall give the member a copy of their training, exposure, participation and clearance records, and shall keep the originals for the retention period. Accountable: {{Health and Safety Officer}}.

### 5.6 Learning records and the firewall

5.6.1 Learning records are held by the learning custodian in {{Learning system}}, apart from incident, personnel and health systems, with access limited to the facilitators of the review and the learning custodian. Accountable: {{Division Chief, Safety}}.

5.6.2 Interview notes and working papers from a post-incident analysis or independent learning review shall not be filed in a personnel file, shall not be provided to a conduct process, and shall be destroyed on closure of the review unless counsel directs they be retained; the final report, de-identified, is retained. Accountable: the learning custodian.

5.6.3 Near-miss and good-catch reports may be made anonymously; where a reporter is identified, the identity is held by the learning custodian only and is removed before the report is shared. Accountable: the learning custodian.

5.6.4 Learning records may be disclosed under access-to-information law or compelled in legal proceedings; the department does not promise otherwise, writes them knowing that, and claims privilege only on counsel’s advice. Accountable: {{Division Chief, Safety}}.

### 5.7 Members’ access to their own records

5.7.1 Every member may see and obtain a copy of their own training, competency, exposure, injury, participation and clearance records on request, within ten working days, without reason given. Accountable: each custodian.

5.7.2 Every member may obtain their own health information from the occupational health provider under the health privacy statute ([J10 Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/j10-privacy-and-health-information)). Accountable: the provider.

5.7.3 A member may ask for a correction; where the custodian declines, the member’s statement of disagreement is attached to the record. Accountable: each custodian.

5.7.4 Learning records that identify the member are available to the member to the extent they do not identify another participant. Accountable: the learning custodian.

### 5.8 Freedom-of-information posture

5.8.1 The department writes every safety record for disclosure under the access-to-information and privacy law that applies to the municipality ([J10 Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/j10-privacy-and-health-information)): facts, roles, dates, decisions and reasons; no opinion about individuals’ character; no personal health information; names only where the purpose requires. Accountable: every author; {{Division Chief, Safety}} for the standard.

5.8.2 Access requests are handled by the municipality’s access coordinator; the department identifies personal information, health information and third-party information for the coordinator’s review and does not release records itself. Accountable: {{Division Chief, Safety}}.

5.8.3 Public summaries of Tier 3 learning reviews, annual reports and dashboard data are de-identified; no cell in a published table has fewer than {{Minimum cell size}} (default seven) members. Accountable: {{Division Chief, Safety}}.

### 5.9 Security

5.9.1 Records are stored in municipally approved systems with role-based access, audit logging where available, and backup; paper records are in locked storage with a sign-out log. Accountable: each custodian; information technology.

5.9.2 A privacy breach is reported to the municipality’s privacy officer the same day, to affected members as the law and the officer direct, and reviewed through the learning system. Accountable: each custodian.

## 6. Roles and responsibilities

Only the differences from [01 Roles and Responsibilities](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities) are stated here.

6.1 **Senior officer responsible for health and safety.** Policy owner; learning custodian; owns the information-sharing protocol; liaison to the municipal privacy officer and records manager.

6.2 **Health and safety officer.** Custodian of injury, exposure, clearance and inspection records; answers member requests.

6.3 **Occupational health provider.** Custodian of health information; reports clearance status only; party to the protocol.

6.4 **Training division.** Custodian of training and competency records.

6.5 **Program managers.** Custodians of their program’s test, maintenance and inspection records.

6.6 **Peer support team lead.** Holds the minimal contact log outside department systems; reports aggregates.

6.7 **Human resources.** Custodian of personnel records; receives no learning or health records.

6.8 **Municipal privacy officer and records manager.** Advise; handle access requests and breaches; approve retention schedule entries.

6.9 **Members.** May access and correct their own records.

## 7. Program and procedures this policy requires

[05 Document Control and Records](https://thehumanfactor.ca/library/fire-service-safety/document-control-and-records); [Medical, Fitness and Wellness Program](https://thehumanfactor.ca/library/fire-service-safety/medical-fitness-and-wellness-program); [Occupational Cancer Prevention, Exposure Tracking and Screening Program](https://thehumanfactor.ca/library/fire-service-safety/occupational-cancer-prevention-exposure-tracking-and-screening-program); [Incident Investigation and Learning Program](https://thehumanfactor.ca/library/fire-service-safety/incident-investigation-and-learning-program); [Psychological Health and Safety and Peer Support Program](https://thehumanfactor.ca/library/fire-service-safety/psychological-health-and-safety-and-peer-support-program); [SWP - Exposure Reporting](https://thehumanfactor.ca/library/fire-service-safety/swp-exposure-reporting); [Form - Exposure Report](https://thehumanfactor.ca/library/fire-service-safety/form-exposure-report).

## 8. Records, confidentiality and disclosure

8.1 This policy’s own records: the custodian and access lists; the information-sharing protocol; disclosure logs; destruction logs; breach reports; member access request logs.

8.2 Held by the policy owner in {{Records system}}, written for disclosure, retained 10 years.

## 9. Reporting

| Report | From | To | When |
|:---|:---|:---|:---|
| Member access requests received and answered within ten days | {{Health and Safety Officer}} | {{Division Chief, Safety}} | Quarterly |
| Exposure records filed per fire and per member (completeness) | {{Health and Safety Officer}} | Occupational Cancer team; JOHSC | Quarterly |
| Clearance currency rate (career and volunteer) | {{Health and Safety Officer}} | Health, Wellness and Rehab team; JOHSC | Quarterly |
| Privacy breaches and disclosures outside access lists | {{Division Chief, Safety}} | Municipal privacy officer; management review | As they occur; annually |
| Retention schedule compliance and destructions | {{Division Chief, Safety}} | Management review | Annually |

## 10. Training requirements

| Role | Minimum training | Refresh |
|:---|:---|:---|
| Every member | What records exist about you, who sees them, how to get them, how to report an exposure (30 minutes at orientation) | Annually, 15 minutes |
| Every officer | Completing incident, injury and exposure reports; what not to write; the duty-restriction rule (one hour) | Every three years |
| Custodians | Records management and privacy briefing from the municipal privacy officer (two hours) | Every three years |
| Learning facilitators | Learning record handling and destruction (in the facilitator course) | Every three years |
| Occupational health provider and peer support lead | The information-sharing protocol | On appointment and at each protocol revision |

## 11. Legal and standards basis

- The applicable OHS statute and regulations, which differ by province and territory: any records and statistics element of the written OHS program and its availability to the committee and to persons entitled ([J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program)); the committee’s access to records during investigations ([J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative)); any default retention period for records the regulations require, and the periods for particular records such as equipment inspection and maintenance records ([J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention); [J15 Equipment Inspection, Ladders and Aerial Devices](https://thehumanfactor.ca/library/fire-service-safety/j15-equipment-inspection-ladders-and-aerial-devices)); and the reporting of serious injuries and dangerous occurrences to the regulator and the compensation board ([J08 Incident Reporting and Investigation](https://thehumanfactor.ca/library/fire-service-safety/j08-incident-reporting-and-investigation)). The Jurisdiction requirements table at the end of this policy lists what to confirm for your province or territory.
- The access and privacy statute for municipal bodies, and the health information statute governing clinicians, which in most jurisdictions makes the contracted physician, clinic and assistance-program clinician custodians or trustees and not the fire department, though in some it reaches a department that holds health information or gives health care ([J10 Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/j10-privacy-and-health-information)).
- Documented information: control, retention, access and protection (ISO 45001:2018, cl. 7.5; CSA Z45001:19).
- Exposure to contaminants and to potentially traumatic events; exposure report retention and access [(NFPA 1550, 2024, ch. 15 and 16)](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-nfpa-1550); medical records confidential and separate [(NFPA 1580, 2025)](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-nfpa-1580); respirator medical records (CSA Z94.4-18).
- Work disability management as a system, using functional information (CSA Z1011:20); any return-to-work cooperation duty in the applicable workers’ compensation law, and the duty to accommodate ([J33 Return to Work, Accommodation and Hours of Work](https://thehumanfactor.ca/library/fire-service-safety/j33-return-to-work-accommodation-and-hours-of-work)).
- The occupational exposure record retention benchmark of employment plus 30 years (OSHA, n.d.-a, 29 C.F.R. § 1910.1020).
- The learning firewall and the separation of learning records [(Dekker, 2016)](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-dekker-2016).
- The CPSE/CFAI accreditation path: exposure records collected and maintained per law, regulation and current research [(CPSE, 2019, criterion 11A.10)](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information#ref-cpse-2019); an information management system that supports investigation (11A.7); training records management (8B.5); documents reviewed at least every three years (9C.3).

## 12. Review and approval

12.1 Reviewed 12 months after adoption, then every three years; after any privacy breach; after any change in access, privacy or health information law or the municipality’s retention schedule; and on JOHSC request.

## 13. Adoption checklist

| Step | Lead | Done |
|:---|:---|:---|
| Confirm the privacy and access statutes that apply to the department with the municipal privacy officer; check each row of the Jurisdiction requirements table against your province’s or territory’s topic pages | Policy owner with counsel |  |
| Complete the custodian table (5.1.1) with system names and access lists | Policy owner |  |
| Sign the information-sharing protocol with the provider, the assistance program and peer support | {{Division Chief, Safety}} |  |
| Separate the learning system from personnel and incident systems; set access controls | Information technology |  |
| Remove any health information from personnel files on counsel’s advice | Human resources |  |
| Set the exposure record fields and the per-member export | {{Health and Safety Officer}} |  |
| Enter the retention periods in the municipal retention schedule | Municipal records manager |  |
| Consult the JOHSC, {{Union}} and {{Volunteer Association}} | JOHSC employer co-chair |  |
| Counsel review | Municipal counsel |  |
| Train custodians and officers; brief members | Training division |  |
| Enter in document control with review date | Policy owner |  |

## 14. Consulting the JOHSC and bargaining agents

| They will ask | Honest answer |
|:---|:---|
| Who sees my medical results? | Your clinician. The department gets fit, restricted or unfit, and the date. Nothing else, ever, in any department file. |
| Can a near-miss report end up in my file? | No. It lives in the learning system, the learning custodian holds any identity, and human resources has no access. |
| Will the committee see individual injury reports? | Aggregate data and de-identified reports, unless a committee member is participating in the investigation under the statute. |
| Why 30 years for exposure records? | Because cancer appears decades after exposure and a claim needs the record. Canadian law sets no period for fire service exposure records ([J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention)); the department adopts the long one. |
| Can I get my records when I leave? | Yes, as a right, and the department gives them to you without being asked. |
| What about freedom of information? | Records can be requested. The department writes them knowing that, removes personal and health information before release, and the municipality’s coordinator handles every request. |

Put the consultation in writing. Record disagreement, adopt what can be adopted, revisit at 12 months.

## 15. Customization and sector variants

> **Note: Customize**
>
> Decide: the system names and custodians; whether the municipality’s retention schedule can carry the 30-year periods or the department keeps a parallel schedule; the peer support contact log retention; the minimum cell size for published tables. Confirm with counsel whether the department is a custodian under the health privacy statute (usually not) and which access statute applies (municipal or provincial) ([J10 Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/j10-privacy-and-health-information)).

> **Tip: Volunteer and composite departments**
>
> For volunteers the participation record is a compensation record, and presumptive coverage may depend on it ([J11 Volunteer Firefighters](https://thehumanfactor.ca/library/fire-service-safety/j11-volunteer-firefighters)); keep it with the same care as the exposure record and give each member a copy annually. A society-run department may be subject to the provincial access statute rather than the municipal one, or to neither; confirm, and adopt the municipal posture anyway.

**Closing disclaimer.** This model policy is general information prepared by The Human Factor for licensed use by {{Department}}. It is not legal advice. Confirm every statutory reference with counsel before adoption.

## Jurisdiction requirements

This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.

| Topic | What to check in your jurisdiction | Page |
|:---|:---|:---|
| OHS Policy and Program | Whether the written OHS program must provide for records and statistics, and who is entitled to see them | [J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program) |
| Joint Committee and Health and Safety Representative | The committee’s access to records during inspections and investigations, and how its minutes must be kept | [J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative) |
| Incident Reporting and Investigation | Which injuries and occurrences must be reported to the regulator and the compensation board, the deadlines, and whether the board notice also counts as notice to the regulator | [J08 Incident Reporting and Investigation](https://thehumanfactor.ca/library/fire-service-safety/j08-incident-reporting-and-investigation) |
| Records Retention | Any default retention period for records the regulations require, the periods for particular records, and whether any period applies to exposure and health records | [J09 Records Retention](https://thehumanfactor.ca/library/fire-service-safety/j09-records-retention) |
| Privacy and Health Information | Which access and privacy statute governs the department’s records (municipal or provincial), and whether the health information statute makes the clinician, or the department, a custodian or trustee | [J10 Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/j10-privacy-and-health-information) |
| Volunteer Firefighters | Whether presumptive coverage for volunteers depends on a participation record or the chief’s written confirmation, and how long that record must be kept | [J11 Volunteer Firefighters](https://thehumanfactor.ca/library/fire-service-safety/j11-volunteer-firefighters) |
| Equipment Inspection, Ladders and Aerial Devices | How long equipment inspection, test and maintenance records must be kept | [J15 Equipment Inspection, Ladders and Aerial Devices](https://thehumanfactor.ca/library/fire-service-safety/j15-equipment-inspection-ladders-and-aerial-devices) |
| Return to Work, Accommodation and Hours of Work | The return-to-work cooperation duty in the workers’ compensation law, and the duty to accommodate | [J33 Return to Work, Accommodation and Hours of Work](https://thehumanfactor.ca/library/fire-service-safety/j33-return-to-work-accommodation-and-hours-of-work) |

## References

Center for Public Safety Excellence \[CPSE\]. (2019). *Fire and emergency service self-assessment manual* (10th ed.). Commission on Fire Accreditation International. <https://cpse.org/wp-content/uploads/2019/08/10th-Edition-FESSAM-Strikethrough-Underline-v.4.pdf>

CSA Group. (2018). *CAN/CSA-Z94.4-18 (R2023), Selection, use, and care of respirators* (5th ed.). <https://www.csagroup.org/store/product/2426374/>

CSA Group. (2019). *CSA Z45001:19 (R2023), Occupational health and safety management systems: Requirements with guidance for use* (adopts ISO 45001:2018 with Canadian deviations). <https://www.csagroup.org/store/product/CSA%20Z45001:19/>

CSA Group. (2020). *CSA Z1011:20 (R2024), Work disability management system*. <https://www.csagroup.org/store/product/CSA%20Z1011:20/>

Dekker, S. (2016). *Just culture: Restoring trust and accountability in your organization* (3rd ed.). CRC Press.

International Organization for Standardization. (2018). *ISO 45001:2018, Occupational health and safety management systems: Requirements with guidance for use*. <https://www.iso.org/standard/63787.html>

National Fire Protection Association. (2024). *NFPA 1550, Standard for emergency responder health and safety* (consolidates NFPA 1500, 1521 and 1561). <https://www.fire-police-ems.com/NFPA1550-2024.shtml>

National Fire Protection Association. (2025). *NFPA 1580, Standard for emergency responder occupational health and wellness* (consolidates NFPA 1581, 1582, 1583 and 1584). <https://www.fire-police-ems.com/NFPA1580-2025.shtml>

Occupational Safety and Health Administration \[OSHA\]. (n.d.-a). *Access to employee exposure and medical records* (29 C.F.R. § 1910.1020). U.S. Department of Labor. <https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1020>