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

Form 2002-41: Approval to Purchase Clothing

Resident Information
Nom du pensionnaire (en caractères d'imprimerie):
Nom de l'etablissement:
Addresse:

No de permis du foyer de soins spéciaux:
Bureau ràgional des foyers de soins spéciaux:
Addresse:
Date:

Purchase Information

1: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

2: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

3: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

4: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

5: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

6: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

7: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

8: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

9: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

10: Qty.:
[ Single ] [ Pair ]

Description (colors, material, etc.):
Estimated Cost: Each Article: Total:
Actual Cost: Each Article: Total:

Totals
Estimated Cost:
Each Article: Total:

Actual Cost:
Each Article: Total:

Authorization
Valid until (date):

Signature of H.S.C. worker

Date:

Note to supplier Itemized invoice to be submitted in triplicate within 30 days.

Personal information collected in this form is necessary for the proper administration of the Homes for Special Care Act, R.S.O. 1990, c.H.12 and Regulation 636 R.R.O. 1990 as amended. The principal purpose of the collection is to assist with assessment, treatment and program planning for the resident. For information about this collection, please contact the Homes for Special Care Regional Officer through the Regional Offices - Hospitals, Long Term Care and Mental Health Services. For Central East, Central West and Toronto contact the Central East office at 465 Davis Drive Newmarket, L3Y 8T2 (905) 954 4690, for the South West, Central South and Central West contact the South West office at 231 Dundas St. London N6A 1H1, (519) 675 7680, for the North and East regions contact the North office at 159 Cedar St. Sudbury P3E 6A5. (705) 564-3130.

White - H.S.C. Office
Pink - Residential Home

2002-41 (01/07)
7530-4991