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
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 duplication and to ensure more uniform statistics, Statistics Canada has entered into an agreement under section 12 of the Statistics Act with the Canadian Institute for Health Information (CIHI) for the sharing of information from this survey. Under section 12 of the Statistics Act you may refuse to share your information with the Canadian Institute for Health Information by writing to the Chief Statistician and returning your letter of objection along with the completed questionnaire in the enclosed return envelope.
Survey purpose:
This survey collects social, financial and operating data required to produce statistics for your industry. For more information, please consult the enclosed reporting guide.
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 1 877 256-2370.
Do you have any questions? Do you need another questionnaire?
For assistance and information please call: 1 888 291-6111
Type of organization (Check one only): Refer to this section in the guide
1 Sole proprietorship
2 Partnership
3 Incorporated company
4 Co-operative
5 Joint venture
6 Government business entity
7 Government
8 Non-profit organization
GST Number / Business Number:
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
Reporting Arrangement
Are you reporting for more than one facility?
1 Yes > If yes, please report the number of facilities you are reporting for with this form
3 No
Name of person completing this questionnaire:
Last Name: (please print)
First Name:
Telephone:
Area Code
Number
Extension:
Facsimile:
Area Code
Number
Title:
Email address:
Fiscal Period
For the purpose of this survey, please report information for your 12-month fiscal period for which the final day occured on or between April 1, 2009 and March 31, 2010. For example, if your fiscal period ended December 31, 2009, please report for the period January 1, 2009 to December 31, 2009.
From
Day
Month
Year
To
Day
Month
Year
A. Ownership – Refer to this section in the guide
(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 – Refer to this section in the guide
1. 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) – Refer to this section in the guide
Number of Days
1. Provincial Health Department or Ministry (i.e., Provincial Health Insurance Plan, Regional Health Authority)
2. Provincial Social Services Department or Ministry (i.e., Provincial Social Services Plan)
3. Other Provincial Department or Ministry (specify)
4. Municipalities, regional or district administration
5. All other, including federal government and self-pay by residents
6. Total days (sum of boxes 131 to 135)
D. Movement of residents – Refer to this section in the guide
Number of Residents
1. In facility on the first day of the fiscal period
2. Admissions during reporting period
3. Total under care (box 151 plus 152)
4. Discharges during reporting period
5. Deaths during reporting period
6. Total separations (box 154 plus 155)
7. 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 – Refer to this section in the guide
Number of Residents
Male
Female
Age Groups (Count each person once only)
1. Less than 10 years
2. 10 to 17 years
3. 18 to 44 years
4. 45 to 64 years
5. 65 to 69 years
6. 70 to 74 years
7. 75 to 79 years
8. 80 to 84 years
9. 85 years and over
10.Total residents (sum of lines 1 to 9)
Grand Total Residents
F. Type of care – Refer to this section in the guide
Please group all residents in facility on the last day of the fiscal period into the following
(Count each person once only)
Number of Residents
1. Room and board only
2. Room and board with guidance/counselling with respect to social, employment, addiction problems,or parental guidance with skilled counselling (i.e., child care homes)
3. Room and board with custodial care and/or special school, sheltered workshop, etc.
4. Type I (i.e., supervision and/or assistance with daily living and meeting psycho-social needs)
5. Type II (i.e., medical and professional nursing supervision, etc.)
6. Type III (i.e., medical management, skilled nursing care, etc.)
7. Higher type
8. Total residents (sum of boxes 228 to 238)
G. Principal characteristics of residents in facility on the last day of the fiscal period – Refer to this section in the guide
(Count each person once only)
Number of Residents
1. Aged (65 years of age and over)
2. Physically Challenged and/or Disabled
3. Developmentally Delayed
4. Psychiatrically Disabled
5. Emotionally Disturbed Children
6. Addictions
7. Transients
8. Others (specify)
9. Total residents (sum of boxes 261 to 271)
* Totals in boxes 157, 221, 240 and 272 should agree.
Personnel – Do not include contract staff or professionals paid by an outside source
H. Personnel – Refer to this section in the guide
Personnel employed on the last day of the fiscal period (excluding casuals)
Total accumulated paid hours during reporting period (including casuals)
Full-time
Part-time
1. Direct Care Services
2. General Services (see definitions)
3. Total (sum of lines 1 & 2)
Hours reported should have corresponding dollar values reported in Section I.
Expenses – You may provide financial statements instead of completing the financial questions.
I. Expenses – Refer to this section in the guide
Financial information should be reported for the most recent fiscal year that ended at any time between April 1, 2009 and March 31, 2010. (Round to nearest dollar)
Salaries and wages
All other expenses
Total
1. Direct Care Services
2. General Services (include all employee benefits in box 462)
3. Other expenses (includes interest, rent, taxes, overhead (head office), depreciation, etc.)
4. Total Expenses (sum of lines 1, 2 & 3)
Dollar values reported should have corresponding hours reported in Section H.
Revenue – You may provide financial statements instead of completing the financial questions. Ensure sections A through H are completed.
J. Source of Revenue – Refer to this section in the guide
Financial information should be reported for the most recent fiscal year that ended at any time between April 1, 2009 and March 31, 2010. (Round to nearest dollar)
Accommodations
Amount
1. Provincial Health Department or Ministry (i.e., Provincial Health Insurance Plan, Regional Health Authority)
2. Provincial Social Services Department or Ministry (i.e., Provincial Social Services Plan)
3. Other Provincial Department or Ministry (specify)
4. Municipalities, regional or district administrations
5. All other (i.e., federal government and W.C.B.)
6. Residents - co-insurance or self-pay
7. Differential - preferred accommodation
8. Total revenue from accommodation (sum of boxes 501 to 507)
9. Other Sundry earnings
10. Total revenue (sum of boxes 508 and 509)
Surplus (box 510 minus box 497)
Deficit (box 497 minus box 510)
Note: Audited data not required
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:
I certify that the information contained herein is complete and correct to the best of my knowledge.
Signature:
Date:
Year
Month
Day
Lost the postpaid envelope?
Please call us at 1-888-291-6111 or fax us at 1-877-256-2370.
Thank you for completing this questionnaire.