Please click the Save button on the bottom of each page and use the Step links to navigate back to a previous section on the Report Harm or Risk of Harm to a Resident(s) form. If you are logged into the portal and do not complete the final step, you may return at a later date to make changes and finalize.
You must complete the Details of the Report step before you can continue with the following steps.
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If you wish to submit this report anonymously, please sign out of the self-service portal.
If you are anonymous, your information will not be given to the home. You can still enter your personal details so that RHRA can contact you for more information.
To change Case Contact Details, please navigate to your Profile page first.
Please provide the name, room number and contact information (if known) of the resident who is the subject of the report.
If another resident was involved, please provide their information below.
If another resident was involved, please provide their information below.
If another resident was involved, please provide their information below.
If you know whether the resident is in a subsidized suite (meaning they receive financial help from the government, a hospital or other program to help pay for their suite) please indicate the source of funding/subsidy below. If you do not know, please leave this field blank.
If you know whether the resident is in a subsidized suite (meaning they receive financial help from the government, a hospital or other program to help pay for their suite) please indicate the source of funding/subsidy below. If you do not know, please leave this field blank.
If you know whether the resident is in a subsidized suite (meaning they receive financial help from the government, a hospital or other program to help pay for their suite) please indicate the source of funding/subsidy below. If you do not know, please leave this field blank.
If you know whether the resident is in a subsidized suite (meaning they receive financial help from the government, a hospital or other program to help pay for their suite) please indicate the source of funding/subsidy below. If you do not know, please leave this field blank.
If the above resident has a Substitute Decision Maker (SDM), please provide their contact information.
If the above resident has a Substitute Decision Maker (SDM), please provide their contact information.
If the above resident has a Substitute Decision Maker (SDM), please provide their contact information.
If the above resident has a Substitute Decision Maker (SDM), please provide their contact information.
A staff member of the home or an external care provider who is alleged or known to be involved in the incident.
Anyone (staff, care provider, family member, friend) who saw the incident taking place.
What is the nature of the incident?
I believe that there is harm or risk of harm to a resident related to (select all types you think apply):
RHRA's Information Access and Privacy Code applies to the information provided to RHRA through this form. The Code is available on RHRA's website here (hyperlink:
https://www.rhra.ca/wp-content/uploads/2023/12/RHRA-MOU-EN-FINAL-SIGNED-June-2023.pdf#nameddest=Schedule_H ). RHRA will restrict its use of any personal information or personal health information collected through this form for the purpose of carrying out its duties under the Retirement Homes Act, including responding to the report and communicating with the person who made the report.
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