Government of Ontario: Ministry of Health and Long-Term Care Homes for Special Care

Home Staff Change Notification

Instructions:

Home Owner / Operator to complete and forward to the Local HSC office.

Name of residential home
HSC License number
Residential home

Type de changement touchant l'effectif (check applicable box and indicate effective date)
increasing staff
Effective date: from to
decreasing staff
Effective date: from to
replacing staff
Effective date:

With staff change indicate the total no. of full-time staff
With staff change indicate the total no. of part-time staff
Ratio of staff to residents

If new Manager, indicated name

I certify that the information provided above is correct.

Name of Home Owner
Signature of Home Owner
Date

3887–41 (01/07)