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The personal information on this form is being collected under the authority of the Health Protection and Promotion Act and will be used for the administration of public health programs. Any questions about the collection of this information should be directed to Kimberley Shaw, Manager, Chronic Disease & Injury Prevention, KFL&A Public Health, 221 Portsmouth Avenue, Kingston, Ontario, 613-549-1232 or 1-800-267-7875, ext. 1558.