Montreal Cognitive Assessment (MOCA)
Family name
Protected when completed.
File No.
Given names
Date of birth (yyyy-mm-dd)
Address and postal code
Date of assessment (yyyy-mm-dd)
The client's personal information is collected under the authority of the Veterans Health Care Regulations for the purpose of administering benefits and
services. Provision of the information is on a voluntary basis. Any personal information recorded on this form is accessible by the individual to whom it relates.
All personal information collected and used is protected from unauthorized disclosure by the Privacy Act. The Privacy Act provides the client with a right to
access his or her own personal information which is under the control of the Department. The Privacy Act also affords the client the right to challenge the
accuracy and completeness of his or her personal information and have it amended as appropriate.
The client may request a copy of this form by writing to the Access to Information and Privacy Coordinator's Office, Veterans Affairs Canada, PO Box 7700,
Charlottetown, PE, C1A 8M9 and by quoting Personal Information Bank No. VAC PPU 020 and/or VAC PPU 030.
Signature
VAC 762e (2010-06)
Designation
Ce formulaire est disponible en français.
Date (yyyy-mm-dd)