Sunnyside Home Caregiver Declaration Form

Required fields are marked with asterisks (*)

As of Monday, October 17, 2022, Residents living in Long-Term Care may designate 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 16 years of age or older
Someone that is fully vaccinated for COVID-19
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.)
Is willing to follow all of the require infection control requirements while visiting (as outlined on the caregiver declaration form)

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

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:

- Visiting restrictions are currently in place, please visit regionofwaterloo.ca/sunnysidehome for the most up to date information
- 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:

What is the name of Caregiver #3?

Phone Number for Caregiver 3:

Email Address for Caregiver #3

Name of Caregiver #4

Phone number for Caregiver #4

Email address for Caregiver #4:

What is the 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:

What is the name of Caregiver #7?

Phone Number for Caregiver 7:

Email Address for Caregiver #7

Name of Caregiver #8

Phone number for Caregiver #8

Email address for Caregiver #8:

If you would like to designate more than 8 Caregivers, please send an email with each additional Caregivers name, phone number and email address to SunnysideCOVIDResponse@regionofwaterloo.ca