ONTARIO WORKPLACE NALOXONE PROGRAM

Privacy Notice

As part of program administration and evaluation of the provision of free naloxone training and/or free nasal spray naloxone kits to Eligible Employers through Ontario’s Workplace Naloxone Program, data related to business type, workplace size, and business postal code, as well as anonymized learner training evaluation results will be collected and disclosed in aggregate to the Ministry of Labour, Immigration, Training and Skills Development (the “Ministry”) and its third-party service providers. The Ministry or its auditors may also request the records of the Rescue 7 Inc related to the Program for audit purposes, including, without limitation, requesting copies of the attestations provided by registrants.

By proceeding with registering for this naloxone training and/or nasal spray naloxone kit, you hereby consent to the collection, use and disclosure of such information, by and to the Ministry, its auditors and its third-party service providers for the purposes set out above.

Any questions about the collection, use, and disclosure of information for the Workplace Naloxone Program by the Ministry can be directed to the Training and Awareness Branch, Prevention Division, Ministry of Labour, Immigration, Training and Skills Development by email at PreventionFeedback@ontario.ca or by phone at 1-416-212-9871.

Question Title

* 1. Employer Business/Organization Name

Employer Name

Mailing address for workplace location

Unit # (enter "NA" if not applicable)

City/Town

Province

Postal Code

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* 2. Name of contact person

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* 3. Email address

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* 4. Confirm email address

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* 5. Phone number

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* 6. Business hours (enter "NA" if not applicable)

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* 7. How many employees are working at this workplace location?

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* 8. Total number of employees employed by the Eligible Employer across all Eligible Workplaces

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* 9. Business type (2-Digit NAICS)

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* 10. This workplace location requires the following

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* 11. Eligible Employers will be required to attest at time of registration that they have not previously registered for or received free training and/or a free naloxone kit through Ontario’s Workplace Naloxone Program for the Eligible Workplace location requested.

I consent that on behalf of company (Employer Name Above), and for workplace addressed listed above, confirm that:

·       I am authorized on behalf of employer to submit this registration and to bind them to the information I have provided.

·       Employer is an Eligible Employer.

·       This workplace location is an Eligible Workplace.

·       This workplace location has not previously been registered for or received workplace naloxone training through Ontario’s Workplace Naloxone Program.

·       The worker/s registered for training herein has/have not previously received free workplace naloxone training through Ontario’s Workplace Naloxone Program.

·       I consent to the collection, use and disclosure of aggregate data related to business type, workplace size, and business postal code, as well as anonymized learner training evaluation results to the Ministry and its third-party service providers for the purposes of program evaluation and processing registration.

·       All the information provided to the program provider is true, correct, and complete. If the information provided is found to be false or fraudulent, the program provider reserves all of its rights and remedies.

If you have any questions about the collection of information you may contact the Training and Awareness Branch, Prevention Division, Ministry of Labour, Immigration, Training and Skills Development by email at PreventionFeedback@ontario.ca or by phone at 1-416-212-9871.

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* 12. Participant #1 - Contact Information

Name

Email Address

Phone Number

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* 13. Participant #1 Enrolment Course Date If Known

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* 14. Participant# 2 - Contact Information

Name

Email Address

Phone Number

ONTARIO WORKPLACE NALOXONE PROGRAM

Privacy Notice

Question Title

* 1. Employer Business/Organization Name

Question Title

* 2. Name of contact person

Question Title

* 3. Email address

Question Title

* 4. Confirm email address

Question Title

* 5. Phone number

Question Title

* 6. Business hours (enter "NA" if not applicable)

Question Title

* 7. How many employees are working at this workplace location?

Question Title

* 8. Total number of employees employed by the Eligible Employer across all Eligible Workplaces

Question Title

* 9. Business type (2-Digit NAICS)

Question Title

* 10. This workplace location requires the following

Question Title

* 11. Eligible Employers will be required to attest at time of registration that they have not previously registered for or received free training and/or a free naloxone kit through Ontario’s Workplace Naloxone Program for the Eligible Workplace location requested.

Question Title

* 12. Participant #1 - Contact Information

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* 13. Participant #1 Enrolment Course Date If Known

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* 14. Participant# 2 - Contact Information

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* 15. Participant #2 Enrolment Course Date If Known