Region of Waterloo Form

Required fields are marked with asterisks (*)

Personal Services Settings Notice of Operation

Please Note: All owner/operators of Personal Services Settings (PSS) are to submit this form at least 14 days prior to opening or adding new services or renovations.


Site and Owner Information

Hours of Operation

Services

Please check all that apply.


Personal information on this form is collected under the authority of the Health Protection and Promotion Act, 1990 and Ontario Regulation 136/18 – Personal Services Settings. The information will be used to maintain an inventory and to conduct investigations related to Infection Prevention and Control. Documents are maintained pursuant to the Municipal Freedom of Information and Protection of Privacy Act, 1991 and the Personal Health Information Protection Act, 2004. Questions regarding the collection, use and disclosure of personal information should be directed to the Office of the Privacy Officer, Region of Waterloo Public Health and Emergency Services, 99 Regina Street South, Waterloo ON N2J 4V3, 519-575-4400.



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