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Personal Data, Voluntary Declaration and Contact in Case of Emergency

(Please print clearly)
Miss Mrs.
Name:
Ms. Mr. Dr.

Date of birth (dd/mmm/yy): Gender: female male other
Social Insurance Number: Exp. Date:
(if SIN begins with “9”, please
provide expiry date) Card presented Photocopy Required
Home address:

Home telephone number:
Location:
Princess Margaret Toronto General Toronto Western
Toronto Rehab Institute other (please specify) ________________
Department:

Voluntary Self-Declaration for Members of Employment Equity Groups:
This voluntary self-declaration of information is used to indicate that you are a member of one or
more of the four groups designated in the Employment Equity Act (EEA): women, Aboriginal
Peoples, persons with disabilities, and members of visible minority groups. As an organization
receiving federal funding UHN is required to collect employment statistics on the four groups
covered under Employment Equity legislation
Your response to the self-declaration questions is completely voluntary, confidential and will be
used for statistical purposes only.
I do not wish I am female I am an I am a person I am a member of a
to self-identify Aboriginal Person with a disability visible minority group

Please list two contacts in case of emergency while you are at work:

Name: Relationship to you:

Telephone number: home cell. business

Name: Relationship to you:

Telephone number: home cell. business

Signature: _______________________________ date: ____________________

rd
(Return completed form to: Human Resources Administration Centre, 3 floor,
R. Fraser Elliott Building, Toronto General Hospital, 190 Elizabeth St.)

Revised 21/02/18