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Personal Data, Voluntary Declaration and Contact in Case of Emergency

                                                                                      (Please print clearly)
                           Miss   Mrs.
                            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:
                              Princess Margaret         Toronto General         Toronto Western
                             Toronto Rehab Institute       other (please specify)       ________________

              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: ____________________

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

                                                                                               Revised 21/02/18
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