Essential Caregiver Attestation

Based on the MOLTC Direction, as of September 9, 2020 essential caregiver(s) are now permitted to enter a Long -Term Care Home. The following outlines the risks and responsibilities for myself who has been designated as an essential caregiver by a St. Joseph’s Villa resident, or his/her substitute decision maker. The safety of myself, and the residents and staff of St. Joseph’s Villa are based on a relationship of trust and expectations of all individuals involved to adhere to SJV policy, which is based on Directives provided by Public Health and the Ministry of Long-Term Care.

By signing this attestation, I acknowledge that I am aware of the world-wide pandemic caused by the Coronavirus (COVID-19) and the evolving nature of the virus. I am aware of the danger of community spread and the risks posed to not only the residents health who I am visiting with but also to other residents and staff of St. Joseph’s Villa. I am also aware of the risk to my own health and agree to practice the outlined safety measures to prevent the spread of the COVID-19/ Coronavirus.

I agree to review and practice the Infection Prevention and Control measures and safety measures outlined on this information sheet. Specifically, I agree to:

1. Use my best efforts to practice social distancing and hand hygiene practices in order to minimize the risk to the resident, myself and others.
2. That I will wear a mask on Villa premises for the entire visit to reduce the risk to the resident(s). I also agree to wear other Personal Protective Equipment as required.
3. That I agree to notify the Villa’s management staff immediately of a potential hazard, or of any information leading to a potential hazard to our operations or the residents who reside here.

I attest that:

• I have not had contact with someone who is suspected of having COVID-19 or exposure to someone suspected of having COVID-19 in the past 14 days as indicated when I screen in.
• I have not visited another home in an outbreak or a resident who is self-isolating or symptomatic as indicated when I screen in.
• I have tested negative on my last COVID-19 surveillance swab.
• I have read/re-read the St. Joseph’s Villa Safe Visiting Policy prior to my first visit and monthly thereafter.
• I have read/watched all Public Health Ontario resources (read Putting on Personal Protective Equipment (PPE) poster, watched the video entitled Putting on Full PPE, video entitled Taking off Full PPE and video entitled How to Hand Wash) before my first visit and monthly thereafter.

My signature below is made freely and voluntarily.

I have read and understood the above statements: