Occupational Health Employee Intake

Welcome to the IERHA Occupational Health Program. As part of your employment with Interlake-Eastern RHA, we ask you to complete this form to support your ongoing health and safety in the workplace.

This form collects the information we need to:

Review your immunization and health history as it relates to your role
Recommend any testing, vaccines, or follow-up needed to reduce workplace risk
Coordinate safe accommodations or protective measures if applicable
Communicate relevant information with you and if needed your healthcare team or employer, in line with applicable privacy laws

The Occupational Health Program is here to help prevent the spread of communicable diseases, support worker wellness, and to provide care that meets provincial safety and immunization guidelines for healthcare workers.

Privacy – Collection Notice

Your personal information is collected under the authority of section 36(1) of The Freedom of Information and Protection of Privacy Act (FIPPA), and your personal health information is collected under section 13(1) of The Personal Health Information Act (PHIA).

The information collected on this form will be used by IERHA Occupational Health to:

To reduce the risk of contracting or transmitting communicable diseases in the workplace
To assess eligibility for occupationally indicated vaccines, testing, and post-exposure follow-up
To determine immunity status and risk to yourself or others in the event of an exposure
To support health system planning, workforce safety, and HR management
To fulfill IERHA’s obligations to protect and promote public health

By completing this form, you give IERHA Occupational Health permission to assess and manage your occupational health needs. If you have questions before you begin, contact Occupational Health:

Occupational Health Nurse
Interlake-Eastern RHA, Selkirk Corporate Office
233A Main Street, Selkirk, MB
204-785-4717 | 204-785-4753 | [email protected]

Occupational Health Employee Intake

"*" indicates required fields

Step 1 of 5

Personal Information

Name*

First Last

Maiden or past names

Phone number

Date of birth (dd-mm-yyyy)*

Country of birth

Province of birth

Mailing address

Street or Box # City Province Postal Code

Position

Work site

A: PROGRAM CONSENT

Program Consent*

1. I understand that IERHA maintains an Occupational Health Surveillance Program designed to identify, assess, and address potential health and safety risks associated with my position. This program may include recommending vaccinations or tests for communicable diseases, managing exposure follow-up, conducting applicable hearing assessments, determining necessary accommodations or work restrictions, and implementing any other measures required under occupational health (OH) protocols in accordance with the Manitoba Workplace Safety and Health Act and Regulations.

2. I acknowledge that IERHA Occupational Safety & Health (OSH) policies and guidelines may be updated in response to new legislation, public health developments, or emerging medical evidence. I agree to complete required training, undergo recommended immunizations and testing, participate in applicable hearing evaluations, and comply with any additional protective measures or follow-up procedures relevant to my role.

3. I consent to the collection, use, and retention of my Personal Health Information (PHI) by IERHA OH in accordance with The Personal Health Information Act (PHIA). My PHI will be used exclusively for OH purposes(e.g., risk assessments, immunization reviews, necessary follow-up). Records will be securely stored for up to thirty (30) years, and access is strictly limited to authorized OH personnel. My PHI will only be shared beyond OH staff when required as mandated by law.

4. I understand that OH may disclose my PHI to external healthcare providers, facilities, or agencies when it is necessary for treatment, follow-up, or if disclosure is required by law or public health guidelines. When sharing information with my employer (e.g., HR or my manager), only the minimum necessary information will be provided to determine work accommodations or restrictions. Beyond these specific instances, my PHI remains confidential under PHIA.

5. I authorize IERHA OH to access, collect and update my immunization and testing records from provincial health databases (e.g., PHIMS, eChart), primary care providers, public health authorities, and other relevant institutions. I further authorize Manitoba Public Health to release a summary of my immunization records to OH for verification. If I possess immunization or testing records not available through these systems (e.g., from out-of-province providers, private clinics, or post-secondary institutions), I will submit them directly to OH.

6. I understand that if I restrict or revoke access to these records, OH may be unable to verify my immunization or testing status, which could affect my eligibility for certain duties. I will address any concerns with OH prior to signing this consent.

7. I understand that IERHA may compile and use aggregated, de-identified employee health data for internal research, quality improvements, or program planning. Any such data will lack personal identifiers and cannot be traced back to me.

8. I understand that this consent is valid throughout my employment with IERHA. If I leave and later rejoin, I maybe required to re-sign this or a similar consent to ensure my records remain accurate. I further acknowledge that I may withdraw or modify my consent by providing written notice to OH; however, doing so might limit my ability to perform certain duties or comply with workplace policies. OH will discuss any potential implications with me before finalizing any changes.

I confirm I have read, understood, and voluntarily agree to the above terms.*

Renovating E.M. Crowe Memorial Hospital’s Emergency Room

Project Overview

The project, currently in the schematic design phase, represents a significant investment in the future of local healthcare services. The project is scheduled to go to tender in late Fall 2025. Renovation is expected to begin during the Winter 2025/2026 season, pending the successful completion of ongoing work at the hospital in Ashern. It is anticipated the project will be completed in spring of 2027.

Physician, staff and community input:

Earlier this year, a public survey generated 142 responses and in-person information sessions on March 6, 2025 saw approximately 150 staff members, physicians and members of the public share their thoughts on the project to renovate the existing ED in Eriksdale. In addition, first nation leaders from the areas serviced by the hospital were consulted on the project as part of its commitment to community involvement. The project team—comprised of design professionals and key stakeholders—will host a second round of public engagement sessions in August 2025. These sessions will provide community members with an opportunity to review the updated design, share feedback, and ask questions.

Community based comments are being integrated into designs to ensure the needs of area residents and staff are reflected and that the new space enhances patient care.

Six themes have arisen from feedback collected. The following is a summary of feedback received. Project scope allows for focus on structural elements of the renovations:

1. Facility & infrastructure improvements

Streamline entry, waiting, and ER pathways • Separate and clearly mark entrances: dedicated ER, visitor and ambulance entrances • Proximity and visibility: ER should be closer to nursing stations for better monitoring • Improved signage and wayfinding: better directional signage • Expanded ER space: larger treatment areas and an increase in patient rooms/beds • Waiting area enhancements: more seating, privacy, and comfort features.

2. Privacy & safety measures

• Increased patient privacy: separate areas for ER patients, visitors, and grieving families • Dedicated family and grieving spaces: safe, private rooms for families in distress • Enhanced security features: secure nurse stations, emergency call systems and isolation areas for crisis patients

3. Staffing & medical services

• More staff needed • Improved staff workspaces: larger workstations, better break rooms and overnight staff accommodations • Extended ER hours: many respondents requested 24/7 ER operation • Recruitment and retention efforts: competitive wages, incentives and staff housing solutions needed

4. Technology & equipment upgrades

• Modernized medical equipment: Investment in new diagnostic tools and imaging systems • Technology integration: implementation of digital systems • Better resource allocation: improved lab and diagnostic services for faster patient care

5. Patient experience & comfort

• Better waiting conditions: separate waiting rooms for critical and non-critical cases • Entertainment and transparency: TVs, wait time displays and better communication for patients • Improved accessibility: wider doorways, wheelchair accessible bathrooms and better patient movement/flow.

6. Operational & long term considerations

• Future-proofing the ER: design considerations for future healthcare needs and community growth • Community-centered decision making: strong demand for ongoing community consultation • Balancing renovation and staffing issues

Emergency Response & Vulnerable Worker Self Declaration

If you need assistance in the event of an emergency situation due to being disabled by one or more barriers in the workplace, or a vulnerable worker we would like to work with you to develop an individualized emergency response plan that will meet your needs.

Please Note: that at this time we do not need to know the details of your medical condition or disability, only the kind of supports you may need. The information provided will be kept confidential. A member of Occupational Safety & Health (OSH) will contact you if you self-declare. The next step would be to work together on a plan.

Please Note: you will need to provide consent for us to share pertinent details, strictly on a need to know basis. For Example: if you need another person to assist you during an emergency, we would request that you allow us to share the relevant information with that manager, co-workers, or fire wardens as applicable.

Request to Conduct Research

Interlake-Eastern RHA supports and promotes research that contributes to the advancement of health care. If you are affiliated with a research project and you are seeking engagement with our patients, clients residents or staff, please fill out the following form.

Request to Conduct Research

IDENTIFICATION

Project Title

Name

Are you still a student?

Yes

No

Address

Street Address City Postal Code

Phone (Work)

Phone (Home)

Email Address

FOR STUDENTS

Please Note: A letter from the course instructor / advisor identifying the student and outlining the purpose of the project is required.

School / University / College

Faculty / Department

Course research is required for?

Course Instructor / Advisor

FOR ALL NON-STUDENT RESEARCHERS

Organization

Position Held

Supervisor Name

Supervisor Job Title

RESEARCH PROJECT DETAILS

Ethical Approval obtained from

Date of Approval (dd-mm-yyyy)

Please Note: Interlake-Eastern RHA will not consider requests for research or information that do not have ethical approval from governing bodies. Please attach confirmation of ethics approval by the body governing this research.

Attach confirmation of Ethics approval

Accepted file types: pdf, doc, docx, txt, rtf, Max. file size: 5 MB.

If affiliated with the region, indicate site / facility

Short Description of Project

Attach Detailed Project Proposal

Accepted file types: pdf, doc, docx, txt, rtf, Max. file size: 5 MB.

Anticipated Start Date (dd-mm-yyyy)

Anticipated Completion Date (dd-mm-yyyy)

Will research results be published?

Yes

No

Indicate where and when, if known

Will the IERHA or the facility / program be identified in the report?

Yes

No

Please Note: You are required to submit a copy of the completed report to the region prior to publication.

What contact will you require with staff? With clients?

What requirements will you have in the region / facility / site?

Name

This field is for validation purposes and should be left unchanged.

MPox (Monkeypox)

Mpox is caused by the monkeypox virus (MPXV), an Orthopoxvirus related to vaccinia, cowpox, and variola (smallpox) viruses. It can cause a painful rash, enlarged lymph nodes, fever and other symptoms. Most people fully recover, but some get very sick.
For the most current and up to date information, including vaccine eligibility, see the Mpox website.
Preventive immunization for eligible people can be booked by contacting your Community Health Office.

French Language Services Questionnaire

This document is available under alternate formats by request. Please contact [email protected] or call 204-367-5402.

The Interlake-Eastern Active Offer Policy states that the Interlake-Eastern Regional Health Authority shall ensure that health services are actively offered in both Official Languages to the extent possible in those areas where the French-speaking population is concentrated, in accordance with the Manitoba French Language Services Policy and the Interlake-Eastern French Language Services Plan.

Please complete the following if you have received health services in one of our designated areas (St. Laurent; Powerview-Pine Falls/RM of Alexander).

Regional Orientation Onboarding

Pledge of Confidentiality

"*" indicates required fields

Name*

First Name Last Name

You are an:*

Employee

Physician

Volunteer

Student – indicate program

Take Your Kid To Work Day

Other

Other please specify:

Section Break

Program/Department

Site

(facility)

Consent*

The Interlake-Eastern Regional Health Authority, as a Trustee, is bound by The Personal Health Information Act (hereinafter called PHIA). Pursuant to PHIA, the Interlake-Eastern RHA is required to protect the confidentiality and privacy of its patients’ and clients’ personal health information. As a result, the Interlake-Eastern RHA will not disclose personal health information except as may be allowed and required by PHIA. The Interlakeu0002Eastern RHA requires that its employees, volunteers, students, and others associated with the Interlake-Eastern RHA act in this manner. All employees and those associated with the Interlake-Eastern RHA must be provided with PHIA education and understand their obligation to comply with PHIA and the Interlakeu0002Eastern RHA’s policies regarding the confidentiality of personal and personal health information. WHAT IS THE PERSONAL HEALTH INFORMATION ACT (PHIA)? PHIA is provincial legislation that incorporates the common law right of an individual to examine and receive a copy of his or her personal health information. It also limits and controls the manner in which personal health information is collected, used, disclosed, stored and destroyed. We are required to protect the privacy and confidentiality of all personal health information obtained, handled, learned, heard or viewed in the course of our work or association with the Interlake-Eastern RHA. The purpose of PHIA is to protect the confidentiality of information provided by individuals to health care professionals so as to ensure that personal health information is protected and individuals are not afraid to seek health care or to disclose sensitive information to health care professionals. PHIA policies are found in the Interlake-Eastern RHA’s General Administration Manual, under section 7, Health Information. WHAT IS PERSONAL HEALTH INFORMATION? All information, whether recorded or exchanged verbally about an identifiable individual that relates to:  The individual’s name, health or health care history, including genetic information, about the individual or the individual’s family;  What is learned or observed, including conduct or behaviour, which may be a result of illness or the effect of treatment;  The provision of health care to the individual. Individuals include co-workers or families of co-workers when they are patients/clients of the Interlake-Eastern RHA;  Payment for health care provided to the individual and includes:  the personal health identification number (“PHIN”) and any other identifying number, symbol or particular assigned to an individual, and  any identifying information about the individual that is collected in the course of, and is incidental to, the provision of health care or payment for health care.  The individual’s personal information, including financial position, home conditions, domestic difficulties or any other private matters relating to the patient/client which have been disclosed to staff or persons associated with the Interlake-Eastern RHA. GA-7-F-6131 PHIA Education Document Pledge of Confidentiality Revised: May 26, 2023 Page 2 of 7 DEMOGRAPHIC INFORMATION  Means an individual’s name, address, telephone number and e-mail address. If information is demographic or his or her PHIN, it can be used to confirm eligibility for health care or payment for health care, verify the accuracy of the demographic information or PHIN, used to collect a debt the individual owes to the trustee, to verify the individual’s eligibility for a program services or benefit, and to assist police in locating an individual reported as being missing. While you are performing your duties with the Interlake-Eastern RHA, you are responsible to:  Keep all patient and client personal health information confidential and private. Do not discuss any patient or client information with anyone who does not need to know this information to do his or her Interlake-Eastern RHA job.  Do not share any patient or client personal health information or any other information provided to you:  In the presence of someone who does not need to know this information  In public places, (i.e., cafeteria, elevators, off premises)  You are required to ensure that all personal health information is properly secured and maintained to protect its confidentiality and to ensure that it is safe from accidental loss or destruction.  Authorized personnel who need to transport personal health information outside the Interlakeu0002Eastern RHA’s premises are required to store laptops, charts, or files in the trunk of their vehicle during transportation and must never leave this information in the trunk of a vehicle in an area of high risk of theft.  All confidential material must be disposed of by an approved method (i.e. shredding).  Anyone faxing personal health information needs to take precautions by using an approved fax cover sheet which clearly indicates that the fax contains privileged or confidential information, that unauthorized disclosure is prohibited, and that the sender should be notified immediately and the original destroyed in the event that it is received by someone other than the intended recipient.  If you are not sure what is the appropriate thing to do in a specific situation, discuss it with your supervisor, manager, site Privacy Officer, or the Interlake-Eastern RHA Regional Privacy Advisor at 785-7240.  Report all suspected breaches of confidentiality immediately to your supervisor/manager. The supervisor/manager must report the suspected breach to the Regional Privacy Advisor in a timely manner and complete an occurrence report. A Breach of Confidentiality Occurs When:  Information is accessed when you don’t need it to do your job.  Personal health information is shared with another employee who does not need it to do their job.  Personal health information is shared with someone outside of the Interlake-Eastern RHA who is not authorized to know the information.  Where consent is required and there is a lack of consent from the patient or authorized representative to share the information.  Patients or clients are identifiable when information is disclosed and patient identification is not authorized. IF a breach of confidentiality is confirmed, discipline may include:  Verbal warning  Written warning  Suspension  Termination of employment GA-7-F-6131 PHIA Education Document Pledge of Confidentiality Revised: May 26, 2023 Page 3 of 7 If convicted of an offence under PHIA, the courts may fine you up to $50,000. A confirmed breach of confidentiality may be reported to the individual’s professional regulatory body. PHIA Policies You are required to have read and understand the following Interlake-Eastern RHA PHIA policies. These policies are summarized below. The complete policies are found in the Interlake-Eastern RHA General Administration Manual, Section 7. Confidentiality of Personal Health Information GA-7-P-50  To ensure that personal health information is protected so that individuals are not afraid to seek health care or to disclose sensitive information to health professionals.  To ensure that personal health information is protected during its collection, use, disclosure, storage, and destruction within the Interlake-Eastern RHA.  All employees and persons associated with the Interlake-Eastern RHA are required to sign a Personal Health Information Pledge of Confidentiality (Appendix A) after having read the PHIA Education Document provided to them.  All employees are required to attend a supplemental PHIA education session provided at regional orientation.  All employees are responsible for protecting the security of all personal health information (oral or recorded in any form) that is obtained, handled, learned, heard or viewed in the course of his/her work or association with the Interlake-Eastern RHA.  Use or disclosure of personal health information is acceptable only in the discharge of one’s responsibilities and duties (including reporting duties imposed by legislation) and based on the need to know. Discussion regarding personal health information shall not take place in the presence of persons not entitled to such information or in public places (elevators, lobbies, cafeterias, off premises, etc.).  Unauthorized use or disclosure of confidential information may result in disciplinary action up to and including termination of employment/contract/association/appointment. Access to Personal Health Information GA-7-P-52  The provisions of The Mental Health Act (Manitoba) take precedence over any conflicting provisions in The Personal Health Information Act.  Individuals have the right to examine and receive copies of their personal health information.  Requests for access to information should be in writing. A Request to Access Personal Health Information form is available for completion (attached to Policy GA 7-52).  Responding to requests for personal health information regarding care currently being provided:  Where a request to examine Personal Health Information is about a hospital in-patient, a member of the Health Care Team or designate shall be present and make the Personal Health Information available for examination only within 24 hrs. after receiving the request. Copies requested must be provided as soon as reasonably possible.  Where a request is from an individual who is not a hospital in-patient, a member of the Health Care team or designate shall make the Personal Health Information available for examination and if requested, a copy of the information must be provided to the requestor within 72 hrs. after receiving the request.  All other requests for information must be provided within 30 days.  Privacy Officers or designates coordinate requests for access to information.  Health care providers may show or share copies of personal health information to clients during assessment, consultation, care and treatment. Access must be documented on the health record.  The request and response for personal health information shall be included in the client’s health record. GA-7-F-6131 PHIA Education Document Pledge of Confidentiality Revised: May 26, 2023 Page 4 of 7  Requests for personal health information may be refused for reasons specified in The Personal Health Information Act. Collection of Personal Health Information GA-7-P-54  Collect only as much personal health information as needed to do your job.  Inform the individual why you are collecting the information and with whom the information may be shared.  Collect information directly from the individual. The exceptions are listed within the policy.  Collect information in a manner and location that protects the confidentiality, security and integrity of that information.  A trustee shall inform the individual of the purpose for collecting information. This may be done by posting notices within the health care facility and/or providing individuals with a brochure. Correction of Personal Health Information GA-7-P-55  Requests for correction of personal health information must be made in writing to the Privacy Officer or designate using the standard correction form or in a covering letter which includes the same information. Disposal of Confidential Material, Including Personal Health Information GA-7-P-56  Confidential material must be disposed of by supervised incineration, shredding or otherapproved methods. Use and Disclosure of Personal Health Information GA-7-P-57  Use is revealing personal health information to someone within the Interlake-Eastern RHA.  Disclosure is revealing personal health information to someone outside of the Interlakeu0002Eastern RHA.  Before using or disclosing health information, reasonable steps must be taken to ensure the information is accurate, up to date, complete and not misleading.  Use of personal health information is limited to “the need to know” for your job.  Requests for disclosure of personal health information are coordinated with the Privacy Officer or designate.  A record of all personal health information disclosed shall be kept on the health record. A Record of Disclosure of Personal Health Information must be completed for every disclosure (see Policy GA 7-57).  The individual’s consent is required to disclose personal health information except under circumstances listed in this policy.  Personal health information may be disclosed without consent if authorized or required to do so by an enactment of Manitoba or Canada, for example, The Child and Family Services Act, The Fatality Inquiries Act, The Missing Persons Act and The Gunshot and Stab Wounds Mandatory Reporting Act.  PHIA allows disclosure to any person requesting information such as the client’s name, condition and location (as long as the location does not reveal specific information about the individual) and provided that such disclosure is not contrary to the express request of the individual or his or her representative.  PHIA allows for demographic information or PHIN to be used to confirm eligibility for health care or payment for health care or verifying the accuracy of the demographic information or PHIN. Security and Storage of Personal Health Information GA-7-P-60  Security safeguards shall be in place to protect personal health information, i.e., locked cabinets, restricted access, security clearances, and passwords.  Users must log off their computers when they leave the workstation.  Computer users must not share their user IDs and passwords.  Personal health information shall not be transmitted via e-mail outside the Interlake-Eastern RHA network. GA-7-F-6131 PHIA Education Document Pledge of Confidentiality Revised: May 26, 2023 Page 5 of 7  Files containing personal health information will be kept in a designated secure storage area and not left unattended on desktops.  Health care providers removing personal health information from the premises on authorized business shall ensure the secure storage of the information at all times. Transmission of Personal Health Information Via Facsimile GA-7-P-61  Use the Record of Disclosure of Personal Health Information and a fax cover sheet whenever faxing personal health information.  The sender is responsible for the security of all personal health information being sent by fax.  Ensure the fax number is correct and the fax machine is located in a secure place. A confirmation sheet must be kept for all personal health information sent via fax.  A guideline is available for use and is attached to this policy. Retention and Destruction of Personal Health Information GA-7-P-65  Personal health information will be retained as per retention periods outlined in the policy. Disclosure of Personal Health Information to Police GA-7-P-66  The Interlake-Eastern RHA will only disclose personal health information to the police which is maintained and collected by the Interlake-Eastern RHA in accordance with PHIA and the regional policies related to PHIA.  Police are required to obtain consent for disclosure of personal health information from the individual the personal health information is about or from a person permitted to exercise the rights of that individual. If the police do not have such consent, a subpoena, warrant, or court order is required.  During normal business hours requests for disclosure of personal health information shall be forwarded to the site Health Information Services Department for processing. Requests will be reviewed to determine the urgency of the request and will be processed accordingly.  After normal business hours, requests for disclosure of personal health information must be discussed with the Clinical Team Manager or management designate who is on call. If the circumstances are not considered to be urgent, the police should be advised to contact the site Health Information Services Department on the next business working day. The only urgent request from Police will be regarding the Missing Persons Act.  Under The Missing Persons Act Police may request access and/or copies of information via a Record Access Order or Emergency Demand when they have a reported missing person. They may also request access to information on a person who may be accompanying the missing person. A guideline is available for reference. Personal Health Information Disclosure Due to Risk of Serious Harm GA-10-P-300  In compliance with provincial legislation and MHSAL policy, all trustees/health professionals are to follow the processes outlined in the policy for the determination, disclosure, and documentation of an individual’s personal health information related to the risk for serious harm to an individual and/or public health or public safety.  Individuals seeking health related services are encouraged and supported to provide consent to disclose PHI when there is an assessed risk of serious harm to the individual and/or public health or public safety.  An individual’s consent to disclose PHI remains best practice. PHI belongs to the individual and trustees are entrusted to use it appropriately. Where a risk of serious harm has been identified through assessment and the individual does not consent to the disclosure of relevant PHI to mitigate this risk disclosure may occur to an identified family member or natural support individual.  Determination of risk must not remove an individual’s basic rights and dignity to determine their own lifestyle choices and acceptable personal risks. Self-determination and personal autonomy are integral principles of personal recovery.  Discussions to build natural supports and preferred contacts into the individual’s profile should be asked for and be part of every episode of care. GA-7-F-6131 PHIA Education Document Pledge of Confidentiality Revised: May 26, 2023 Page 6 of 7  Collaborative decision: When risk is not immediate, the determination to disclose PHI without consent in order to lessen risk of serious harm is reviewed by at least two trustees/health professionals within the interdisciplinary care team.  The decision to disclose PHI is clearly determined based on the individual’s needs and best interests. Disclosure is never considered solely or principally from the perspective of risk mitigation to the health professional.  Once the risk has passed, the disclosure of further PHI without consent is no longer authorized. Data Collection and Research Activities GA 7- P-95  Personal health information may be disclosed for health research after approval from the Institutional Research Review Committee or designate.  Consent will be obtained from the individual when personal health information will be disclosed. Disclosure of Personal Health Information to Religious Organizations GA-7-P-49  Notices must be posted to inform hospital in-patients and residents of personal care homes that their names, condition and location may be provided to a representative of their religious organization. Notices will also advise of the ability to object to the disclosure of their information.  The Spiritual Care Coordinator(s) will provide sites with a list of religious organizations and their representatives that may receive this information.  A consent to visitation by spiritual representatives form will be completed for every patient at sites that do not have 24 hr. admitting coverage. Sites that have 24 hr. coverage will record this information in their ADT system upon admission. Disclosure of Personal Health Information to Affiliated Foundations GA-7-P-47  Hospitals and personal care homes may disclose an individual’s name and mailing address, if they have received services from the hospital/personal care home, to a charitable fundraising foundation affiliated with the health care facility unless: 1. The individual has objected to the disclosure 2. The individual has died while in the hospital/personal care home 3. The individual is under the age of 18.  Notice must be provided to individuals advising that their names and addresses may be provided to the fundraising foundation affiliated with the facility. Notices will also advise of the ability to object to the disclosure of their information

I read and understand the Personal Health Information Act “PHIA” above

Signature

Please note: the date will automatically be applied to this document upon submission.

By signing this form I have read and understood the Personal Health Information Act policy shown above.

Comments

This field is for validation purposes and should be left unchanged.

Employee ID Tag Request

"*" indicates required fields

EMPLOYEE INFOMATION

Legal Name*

First Name Middle Name Last Name

(as it appears on your SIN card)

SHIPPING CONTACT & ADDRESS INFORMATION

(please complete in full to avoid delivery delays & returned mail)

Contact Name*

IERHA Site Name*

IERHA Site Address

TAG INFORMATION

Tag request for:*

New Employee

Lost ID

Damaged Id

New Position

Badge type:*

Clip

Lanyard

Lanyard or Clips are provided for NEW & LOST IDs, or if they are damaged
A non-refundable $20 fee. processed via payroll deduction for replacing LOST IDs
Damaged IDs must be returned to ID Badge Requests at: Corporate Office (please include this form)
Old IDs must be returned to Badge Requests at: Corporate Office (please include this form)

Notes:

First or Preferred Name*

How would you like your name to appear on you ID

Position*

DO NOT use abbreviations for Position

Shared Health Employee ID #

Attatch an image: please make sure that the image has a plain background, and it displays your shoulders and above.*

Accepted file types: jpeg, jpg, png, bmp, gif, Max. file size: 10 MB.

Name

This field is for validation purposes and should be left unchanged.

Employee Demographics

"*" indicates required fields

Name*

First Name Last Name

Social Insurance Number*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Marital Status

Gender

Emergency Contact

Name*

Relationship*

Phone*

Banking Information

Direct Deposit Information*

Accepted file types: jpg, jpeg, png, gif, , Max. file size: 8 MB.

Please attach an unsigned, voided cheque image

Parking Pass Information

Parking Privileges Request*

Apply for Parking Privileges

Decline Parking Privileges

Cancel Parking Privileges

I understand that an established amount will be deducted from my pay cheque and that the fee may change from time to time according to economic conditions. The fee in effect at the present time may be obtained from the Payroll Department.

I understand that cars parked on the premises without a parking tag will be towed away at the employee’s expense. I understand that staff are not permitted to park in the visitor or emergency/out patient areas and that parking in these areas will result in disciplinary action and/or suspension for violation of Authority policy.

I understand that I am to notify the Payroll Department of any vehicle changes so that accurate records can be maintained.

List

Vehicle Make

Color

License #

Parking Tag #

I elect to contribute to the Five Dollar Club?*

Yes

No

Email

This field is for validation purposes and should be left unchanged.

Below please find additional forms and information, please note that these are not required to be completed and submitted unless you choose to do so:

IERHA Payroll Calendar

TD1 Form – Provincial

TD1 Form – Federal

Guide To Viewing Pay Statements Online

Five Dollar Club Sign Up

Manitoba Blue Cross iCBT Information Sheet

How to Apply for Jobs on QSS

Mental Health Test Questionnaire

Well Wishes

A photo of a white wall with pinecones, snowflakes and pine tree leaves.

We welcome family members and friends to send well wishes to patients in hospital. Please use the form below to identify your message and staff in facility will print and deliver (and read if needed) your message to your intended recipient. An asterisk beside a field means it is required information.

We strive to distribute messages received during working hours (Monday to Friday, 8 a.m. to 3:30 p.m.) on the same day. After hours messages will be delivered the next day and messages received on the weekend will be delivered Monday. Statutory holidays will also affect timing of message delivery.

PLEASE NOTE: Messages will not be forwarded in the event of a patient’s discharge or if no patient can be identified based on the information provided. This site is intended for the purposes of delivering well wishes only to hospital patients. We can not reply to patient inquiries through this website nor will we deliver messages sent for: conducting personal business, containing or requesting diagnoses and/or treatment information; business/vendor solicitations; questionable content given these parameters.

Please contact the hospital where the patient is admitted for all patient inquiries.

Compliments & Concerns

Elderly man with glasses and white beard showing a small girl with light-coloured hair something on his finger. She is sitting on his lap and wearing a light grey collared shirt, an elderly lady with light-coloured hair looks at his finger as well in the background, they are sitting on a deck overlooking a body of water

Do you have something to say about the healthcare services you have received in our Region? Do you have a question, a compliment or a concern?

We are here to listen and help

The Patient Relations department gives patients and families an opportunity to give feedback about their healthcare experience. We can help resolve concerns, or navigate the healthcare system. If your concern is regarding a loved one, we may need their consent to look into the matter.

If you are comfortable, talk to your care team

They know you best, and they may be able to address your concerns quickly. You can talk to your doctor, nurse or the unit manager.

If you need help, or are not comfortable discussing matters with your team, you can contact Patient Relations.

Your concerns will be taken seriously. Some concerns can be resolved quickly, others may take time. During this process, you will receive regular contact from our office. The lessons learned from the process help improve the quality of patient care in our Region.

We can be reached at 1-855-999-4742 or [email protected].

Or fill in our fillable form below.

Does your concern involve Emergency Response Services or Diagnostic Services through a medical laboratory?

Please contact: Shared Health Patient Relations 204-787-2704 or [email protected]

We try to return all calls within three business days. You can help by leaving your name, contact phone number, email and details of your concern including the facility where you received care.

If you are filling in the following form on behalf of someone, please fill in a: Patient Advocate Agreement

Compliments and Concerns

"*" indicates required fields

Interlake-Eastern RHA Community/Location where the service was received:

Filled out by

Patient or client

Family or friend

If your concern is about a family member or someone close to you, we may need to know more about the patient you are calling about, and they will need to give us legal permission to look into their care.

The Personal Health Information Act requires us to obtain their consent prior to sharing any personal health information.

Would you like a response to your comments?

Yes

No

Name*

First Last

Phone*

Email Address

Patient/Client/Resident Name if different from above

Comments

Name

This field is for validation purposes and should be left unchanged.

Occupational Health Employee Intake

Occupational Health Employee Intake

Privacy – Collection Notice

Occupational Health Employee Intake

Personal Information

A: PROGRAM CONSENT

B: INFORMATION SHARING CONSENT

C: ELECTRONIC COMMUNICATION CONSENT

Acknowledgment & Signature

Renovating E.M. Crowe Memorial Hospital’s Emergency Room

Renovating E.M. Crowe Memorial Hospital’s Emergency Room

Project Overview

Physician, staff and community input:

Six themes have arisen from feedback collected. The following is a summary of feedback received. Project scope allows for focus on structural elements of the renovations:

Emergency Response and Vulnerable Worker Declaration

Emergency Response & Vulnerable Worker Self Declaration

Emergency Response and Vulnerable Worker Self Declaration

Request to Conduct Research

Request to Conduct Research

Request to Conduct Research

IDENTIFICATION

FOR STUDENTS

FOR ALL NON-STUDENT RESEARCHERS

RESEARCH PROJECT DETAILS

MPox (Monkeypox)

MPox (Monkeypox)

French Language Services Questionnaire

French Language Services Questionnaire

French Language Services Questionnaire

Regional Orientation Onboarding

Regional Orientation Onboarding

Regional Orientation Onboarding

General Information

Conflict of Interest Information

Bilingual Information

Additional Bilingual Information

Bilingual French / English Employees Only

Self-Declaration Information

Driver License Information

Media Consent

Pledge of Confidentiality

Pledge of Confidentiality

Pledge of Confidentiality

Section Break

Employee ID Tag Request

Employee ID Tag Request

Employee ID Tag Request

EMPLOYEE INFOMATION

SHIPPING CONTACT & ADDRESS INFORMATION

TAG INFORMATION

Employee Demographics

Employee Demographics

Employee Demographics

Emergency Contact

Banking Information

Parking Pass Information

Mental Health Test Questionnaire

Mental Health Test Questionnaire

Mental Health Questionnaire

Well Wishes

Well Wishes

Well Wishes

Compliments & Concerns

Compliments & Concerns

We are here to listen and help

If you are comfortable, talk to your care team

We can be reached at 1-855-999-4742 or [email protected].

Or fill in our fillable form below.

Does your concern involve Emergency Response Services or Diagnostic Services through a medical laboratory?

Please contact: Shared Health Patient Relations 204-787-2704 or [email protected]

Compliments and Concerns