Assisted Living Report

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Form Instructions

DCI# 455937.GCIMS (2015–2016)

Privacy Act Statement

This statement explains the purposes for the collection and use of personal information. Only information needed to respond to program requirements will be requested. Collection and use of personal information is in accordance with the Privacy Act. In some cases, information may be disclosed without your consent pursuant to subsection 8(2) of the Privacy Act.

The collection and use of personal information for this Assisted Living Sub-Program within Social Development is derived from the Department of Indian Affairs and Northern Development Act, R.S.C., 1985, c. I-6, as well as from annual Appropriation Acts granting authority to the Government to spend funds on programs. We will use personal information for assessing and determining eligibility for the administration of the program to which you are applying, and for reporting on aggregated results. We share the personal information you give us with those as outlined under AANDC PPU 215 detailed at Info Source. The information collected will be retained for a period of five years, then sent to Library and Archives Canada.

As stated in the Privacy Act, you have the right to access the personal information you give us and request changes to incorrect information. Contact your regional office to notify us about incorrect information, or contact the AANDC Public Enquiries by phone at 1 (800) 567-9604 for general enquires.

For more information on privacy issues and the Privacy Act in general, you can consult the Privacy Commissioner at 1 (800) 282-1376.

Funding Recipient Name

Recipient Number

Region

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)

Date modified: