Required fields are marked with asterisks (*)

Sunnyside Home Caregiver Designation Form

As of Monday, July 12, 2021 Residents living in Long-Term Care may choose to have an unlimited number of “Caregiver” visitors.

Caregivers provide direct care and support to a resident (e.g., supporting assistance with meals, mobility, personal hygiene, cognitive stimulation, emotional support etc). Caregiver visits do not need to be scheduled.

A caregiver visitor is defined as:

Someone that is 18 years of age or older
designated in writing by the resident or substitute decision maker (SDM)
Visiting to provide direct care to the resident (e.g. assisting with a meal, personal hygiene, emotional support etc.)

Caregivers must:

Be willing to provide direct care (e.g. assisting with a meal, personal hygiene, emotional support etc.)
Answer screening questions and undergo a Rapid Test for COVID-19 before entering the Home
Complete mandatory training on personal protective equipment
Commit to following the infection control guidelines and requirements

Designating caregivers is optional; the purpose of this form is to determine your wishes. Sunnyside will use the information from this form as part of the screening process when Caregivers arrive at Sunnyside Home to visit.

I am a:

Sunnyside Home Resident

Substitute Decision Maker for a Sunnyside Home Resident

Name of Resident:

Location of Resident's Room:

Contact Information for the person completing this form (Residents may skip this question):

Name:

Phone Number:

Email Address:

If we have questions about this form, may we contact you by email?

Yes

We are required by the Ministry of Long-Term Care to provide education to each Caregiver Visitor on the proper use of Personal Protective Equipment before their first visit. Our preferred method of meeting this requirement is to email links to videos to watch on your computer or smart phone before you visit Sunnyside. If applicable, please provide an email address for both Caregivers. If a Caregiver does not have access to a computer, we will contact you to make alternate arrangements for the training before the first visit.

To avoid delays, please review the email addresses carefully to ensure that they are entered correctly.

Important things to note about Caregiver Visits:

Please allow for two full business days for this form to be processed (this does not include the day on which the form was submitted).
If you provided an email address and are a new Caregiver, we will email you the information listed in this section along with the links to the educational videos. The education must be completed before your first visit.
If you have any questions about this form or about visits to Sunnyside Home, please call the COVID hotline at 519 893 8494 extension 6868.

What is the name of Caregiver #1?

Phone Number for Caregiver 1:

Email Address for Caregiver #1

Name of Caregiver #2

Phone number for Caregiver #2:

Email address for Caregiver #2:

Name of Caregiver #3

Phone Number for Caregiver #3

Email for Caregiver #3

Name of Caregiver #4

Phone Number for Caregiver #4

Email for Caregiver #4

Name of Caregiver #5

Phone number for Caregiver #5

Email address for Caregiver #4

Name of Caregiver #5

Phone Number for Caregiver #5

Email address for Caregiver #5

Name of Caregiver #6

Phone number for Caregiver #6

Email address for Caregiver #6