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Personal Data, Voluntary Declaration and Contact in Case of Emergency

(Please print clearly)
Miss Mrs.
Name:
Ms. Mr. Dr.
Gender: female
Date of birth (dd/mmm/yy):
male
Social Insurance Number: none of the above
(if SIN begins with “9”, please
provide expiry date) Exp. 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): Aboriginal Peoples,
members of visible minority groups, persons with disabilities, and LGBTQ2S identification. 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 an I am a member of a I am a person I identify as
to self-identify Aboriginal Person visible minority group with a disability LGBTQ2S

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: People & Culture, Employee Records & Payroll, 3 floor,
R. Fraser Elliott Building, Toronto General Hospital, 190 Elizabeth St.)

Revised 28/12/22