Confidential when completed
This annual survey is conducted under the authority of the Statistics Act, Revised Statutes of Canada 1985, Chapter S19.
Completion of this questionnaire is a legal requirement under the Statistics Act.
Correct mailing address information if necessary using the corresponding boxes below:
Legal Name:
Business Name:
Mailing Address:
City:
Province/Territory:
Postal Code:
Language Preference:
1 English
2 French
Last name of facility contact:
First name of facility contact:
Title of facility contact
Confidentiality:
Statistics Canada is prohibited by law from releasing any information from this survey which would identify any person, business, or organisation, unless consent has been given by the respondent or as permitted by the Statistics Act. The information from this survey will be treated in strict confidence, used for statistical purposes and published in aggregate form only. The confidentiality provisions of the Statistics Act are not affected by either the Access to Information Act or any other legislation.
Data Sharing Agreement:
To reduce the respondent burden, Statistics Canada has entered into data-sharing agreements with provincial and territorial statistical agencies and other government and non-government organizations, which must keep the data confidential and use them only for statistical purposes. Information on data-sharing agreements and record linkages can be found in the guide accompanying the questionnaire.
Survey purpose:
This survey collects social, financial and operating data required to produce statistics for your industry.
Coverage:
Please complete a questionnaire for the operation and location described on the label. You should only report for those facilities located in Canada.
Return of questionnaire:
Please complete and return your questionnaire within 30 days of receipt Please note that audited data is not required for this survey. Please send the completed questionnaire in the enclosed envelope or by facsimile toll-free to 1 888 883-7999.
Statistics Canada advises you that there could be a risk of disclosure during facsimile or other electronic transmission. However, upon receipt, Statistics Canada will provide the guaranteed level of protection afforded all information collected under the authority of the Statistics Act.
Do you have any questions? Do you need another questionnaire? For assistance and information please call: 1 800 565-1685
Name of person completing this questionnaire:
First Name:
Telephone:
Extension:
Facsimile:
Title:
Email address:
Reporting Instructions:
– Please DO NOT wait for audited financial statements before completing the survey. – When precise figures are not available, please provide your best estimate.
– Please DO NOT include commas, decimals or special symbols ($,#,%, etc.) with your report. – Please consult the reporting guides at www.statcan.gc.ca/ for additional information.
A. Administrative characteristics
Section contains administrative questions regarding the reporting of your facilities
1. Please indicate your type of organization (Check one only).
1 Sole proprietorship
2 Partnership
3 Incorporated company
4 Co-operative
5 Joint venture
6 Government business entity
7 Government
8 Non-profit organization
2. Does your business have a GST Registration Account Number or a Business Number (BN)?
1 Yes > If yes, please report your GST number or Business Number
3 No
3. Are you reporting for more than one facility on this questionnaire?
For facilities that operate more than one location under a single legal entity and for which a single consolidated income statement only is available, please answer ‘Yes’ and report for the number of locations. If you are reporting for one or more facilities that are distinct legal entities with individual income statement, please answer ‘No’ and respond individually for each facility. If you have questions on this, please refer to the guide or contact us at 1-800-565-1685.
1 Yes > If yes, please report the number of facilities you are reporting for with this form
3 No
4. Please indicate your fiscal period.
For the purpose of this survey, please report information for your 12-month fiscal period for which the final day occurred on or between April 1, 2010 and March 31, 2011. For example, if your fiscal period ended December 31, 2010, please report for the period January 1, 2010 to December 31, 2010.
From
Year
Month
Day
To
Year
Month
Day
5. Please indicate your type of ownership ( Check one only ).
Proprietary
Religious
Lay (i.e., not for profit, non-profit voluntary associations, societies)
Municipal
Provincial or Territorial
Federal
Regional Health Authority, Board, District, Corporation
B. Number of beds as of the last day of the fiscal period
6. Please report the number of beds licensed or approved by provincial or municipal authorities and the number of beds available for use.
Number of beds (including respite beds)
Licensed or approved
Staffed and in operation (in use or vacant)
C. Total days of care (by responsibility for payment)
7. Please report the number of days of care by responsibility of payment.
Number of Days
a. Provincial Health Department or Ministry (i.e., Provincial Health Insurance Plan, Regional Health Authority)
c. Provincial Social Services Department or Ministry (i.e., Provincial Social Services Plan)
Other Provincial Department or Ministry (specify)
b. Municipalities, regional or district administration
d. All other, including federal government and self-pay by residents
f. Total days (sum of boxes 131 to 135)
D. Movement of residents – Refer to this section in the guide
8. Please report the number of residents in each of the following categories.
Number of Residents
a. In facility on the first day of the fiscal period
b. Admissions during reporting period
c. Total under care (box 151 plus 152)
d. Discharges during reporting period
e. Deaths during reporting period
f. Total separations (box 154 plus 155)
g. In facility on the last day of the fiscal period (box 153 minus 156)
* Box 157 must agree with boxes 221, 240 and 272.
E. Age and sex of residents in facility on the last day of the fiscal period
Number of Residents
Male
Female
Age Groups (Count each person once only)
a. Less than 10 years
b. 10 to 17 years
c. 18 to 44 years
d. 45 to 64 years
e. 65 to 69 years
f. 70 to 74 years
h. 75 to 79 years
k. 80 to 84 years
l. 85 years and over
n.Total residents (sum of lines a. to l.)
10. Grand Total Residents
* Box 221 must agree with boxes 157, 240 and 272.
F. Type of care
11. Please report the number of residents per type of care received on the last day of the fiscal period. (Count each person once only)
Number of Residents
a. Room and board only
b. Room and board with guidance/counselling with respect to social, employment, addiction problems,or parental guidance with skilled counselling (i.e., child care homes)
c. Room and board with custodial care and/or special school, sheltered workshop, etc.
d. Type I (i.e., supervision and/or assistance with daily living and meeting psycho-social needs)
e. Type II (i.e., medical and professional nursing supervision, etc.)
f. Type III (i.e., medical management, skilled nursing care, etc.)
*Box 240 must agree with boxes 157, 221 and 272.
G. Principal characteristics of residents in facility on the last day of the fiscal period
12. Please report the number of residents by the most appropriate principal characteristic. (Count each person once only)
Number of Residents
a. Aged (65 years of age and over)
g. Higher type
i. Total residents (Sum of boxes 228 to 238)
d. Psychiatrically Disabled
e. Emotionally Disturbed Children
f. Addictions
g. Transients
h. Others (specify)
l. Total residents (sum of boxes 261 to 271)
* Totals in boxes 157, 221 and 240.
Personnel – Do not include contract staff or professionals paid by an outside source
H. Direct care to residents
13. Please report all personnel whose time is mainly spent on direct care to residents in the following
Hours reported for salaries and wages should have corresponding dollar values in Section J.
Personnel employed on the last day of the fiscal period (excluding casuals)
Full-time
Part-time
Total accumulated paid hours during reporting period (including casuals)
a. Registered nurses
b. Registered qualified nursing assistants/licensed practical nurses
c. Physiotherapists/occupational therapists
e. Other therapists (specify)
g. Activity/recreation staff
f. Other direct care staff not included above (specify)
g. Total direct care staff
I. General services
14. Please report all personnel offering general services in the following
Hours reported for salaries and wages should have corresponding dollar values in Section K.
Personnel employed on the last day of the fiscal period (excluding casuals)
Full-time
Part-time
Total accumulated paid hours during reporting period (including casuals)
a. Administration (Include Unit/Ward Clerks)
b. Dietary (i.e., kitchen/food services)
c. Housekeeping /laundry
d. Plant operation, maintenance and security (i.e., janitorial services)
e. Other general services staff (specify)
f. Total general services staff
g. Tatal staff (Sum of lines 13.g and 14.f)
Hours reported should have corresponding dollar values reported in Sections J and K.
Expenses – You may provide financial statements instead of completing the financial questions. Ensure pages 1, 2, 3, 4 and 5 are completed.
J. Direct care to residents expenses
15. Please report the costs of operating and maintaining the facility that are attributed to direct care to residents in the following categories.
Dollar values reported for salaries and wages in Sections J and K should have corresponding hours reported in Sections H and I.
Financial information should be reported for the most recent fiscal year that ended at anytime between April 1, 2010 and March 31, 2011. (Round to nearest dollar).When precise figures are not available, please provide your best estimates
Salaries and wages
All other expenses
Total
a. Registered nurses
c. Registered qualified nursing assistants/licensed practical nurses
c. Physiotherapists/occupational therapists
e. Other therapists (specify)
g. Activity/recreation staff
f. Other direct care staff not included above (specify)
g. Drugs (include oxygen/medical gases)
h. Medical and surgical supplies
i. Other supplies (specify)
j. Total - direct care expenses (sum of lines a. to i.)
K. General services expenses
a. Administration (include all employee benefits in the middle box )
b. Dietary (i.e., kitchen/food services)
c. Housekeeping / laundry
d. Plant operation, maintenance and security (i.e., janitorial services)
e. Other (specify)
f. Total - general services expenses (sum of lines a. to e.)
M. Other expenses
19. Please report all other expenses such as interests and
a. Other (includes interest, rent, taxes, overhead (head office), depreciation, etc.)
b. Total expenses (sum of lines 15..J. + 16.f. +17.a.)
Revenue – You may provide financial statements instead of completing the financial questions. Ensure pages 1, 2, 3, 4 and 5 are completed.
M. Source of Revenue
18. Please report the revenues by their source.
Financial information should be reported for the most recent fiscal year that ended at anytime between April 1, 2010 and March 31, 2011. (Round to nearest dollar)
When precise figures are not available, please provide your best estimates.
Accommodations
a. Provincial Health Department or Ministry (i.e., Provincial Health Insurance Plan, Regional Health Authority)
b. Provincial Social Services Department or Ministry (i.e., Provincial Social Services Plan)
c. Other Provincial Department or Ministry (specify)
e Municipalities, regional or district administrations
g. All other (i.e., federal government and W.C.B.)
f. Residents – co–insurance or self–pay
g. Differential – preferred accommodation
h. Total revenue from accommodation (sum of boxes 501 to 507)
i. Other Sundry earnings
j. Total revenue (sum of boxes 508 and 509)
k Surplus (box 510 minus box 497)
l. Deficit (box 497 minus box 510)
I certify that the information contained herein is complete and correct to the best of my knowledge.
Signature:
Date:
Year
Month
Day
Thank you for completing this questionnaire.
1.How long did you spend collecting the data and completing this form? hours minutes
2. Comments? We invite you to assist us in improving the survey. Your comments and general remarks would be greatly appreciated:
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