Sunnyside Home Caregiver Designation Form

Residents living in Long-Term Care may choose to have up to two “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

What is the name of Caregiver #1?

What is the name of Caregiver #2 (if applicable)?

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.

Email Address for Caregiver #1

Phone number for Caregiver #1:

Email address for Caregiver #2:

Phone number for Caregiver #2:

Important things to note about Caregiver Visits:

The Caregivers listed on this form may be updated in response to changes in a resident’s care needs and/or based on the availability of the designated caregivers by completing and submitting a new form. Please allow for two full business days for the changes to be processed (this does not include the day on which the form was submitted).
The electronic version of the form can be found on the Region of Waterloo website or by typing the address (url) into your computer browser: tinyurl.com/sunnysidevisitor
Blank copies of the paper version of this form can be found in a folder that is attached to the Caregiver Designation Form return box located in the vestibule to the main entrance of Sunnyside Home.
Please allow for 2 full business days for us to process paper and electronic forms. This does not include the day that you submitted your form.

If you provided an email address we will email you the information listed in this section along with the links to the educational videos. 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.