Assisted Living Report

PDF Version - Fill & Print (157 Kb, 1 Page)

Form Instructions

DCI# 455937 (2014–2015)

Privacy Act Statement

The information you provide in this document is collected under the authority of the Department of Indian Affairs and Northern Development Act for the purpose of assessing performance, allocating funds, and in determining, if applicable, eligibility for reimbursement. Information on individuals is used by Aboriginal Affairs and Northern Development Canada's Income Assistance Program employees who need to know the information in order to respond to your request and/or the program requirements. We do not share the personal information with other federal government departments. However, in exceptional circumstances, case specific information may be discussed with Health Canada and/or the province/territory under whose jurisdiction the recipient may fall. The personal information will be kept for a period of five years after which it will be sent to archives. Individuals have the right to the protection of and access to their personal information under the Privacy Act. The information collected is described under the Personal Information Bank INA SEP 502 which is detailed at InfoSource.

Funding Recipient

Name

Recipient Number

Reporting Period (YYYYMMDD)

From

To

Client Information

Band
Number
Given Name
(First)
Family Name
(Last)
Sex Date of Birth
(YYYY
MMDD)
Name of Institution or Foster  Care  Home (if applicable) Parent/
Guardian/
Trustee
(Optional
Field)
Given Name /
Family Name
Assessment Date (YYYY
MMDD)
Type
of Service Need Assessed
Type
of
Service
Provided
Care
Start Date (YYYY
MMDD)
Care
End Date (YYYY
MMDD)
Rate
($)
Rate Unit Total Number of Units Total ($)
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               

Total

The information provided is accurate to the best of my knowledge.

Given Name

Family Name

Title

Date (YYYYMMDD)