Compliments & Concerns

We’d like to hear your compliments and concerns.

Southern Health-Santé Sud focuses on providing high quality, safe, people-centered care that matters to patients. We have a culture of continuous improvement and your feedback matters. Let us know what we are doing well or where we need to improve!

We offer a number of ways to communicate with us:

• Complete the electronic form below. (Printed forms can be requested from staff)
• Speak to your healthcare provider or staff member.
• Compliment or concern? Call us toll free at 1-800-742-6509.

Thank you very much for your comments and your efforts to make us a better health authority for you and your family.

If you are not the patient / client / resident:

• The Personal Health Information Act (PHIA) states that consent must be obtained from the patient/client/resident to discuss their health information with anyone other than the patient/client/resident. You may be asked to fill in a patient advocate agreement form before we can release health information with anyone other than the patient/client/resident.

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

We are committed to fostering a positive, respectful, and inclusive environment for everyone. As such, any form of disrespectful language, harassment, or bullying will not be tolerated. This includes, but is not limited to, offensive remarks, discriminatory behavior, threats, or any actions that create an unsafe or unwelcoming space.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Request to Access, Correct or Disclose Personal Health Information (PHI)

ORG.1411.PL.101.FORM.01, ORG.1411.PL.104.FORM.01 & ORG.1411.PL.502.FORM.01

Do not use this form if requesting information related to your visit to a  laboratory or radiology department, including Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) scan, Contact: Privacy and Security at Shared Health or eChart Manitoba.

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Request to Access, Correct or Disclose PHI

"*" indicates required fields

Step 1 of 3

33%

I am requesting…*

access to personal health information (PHI)

the trustee to disclose personal health information (PHI) to a third party

a correction to personal health information (PHI)

This request is being made…*

For myself

On behalf of another individual

This form is to be used when requesting PHI about yourself or another individual you are permitted to exercise the rights of. You may be required to provide two pieces of identification prior to receiving the PHI requested.

A base fee of $15 may be applied. Additional costs may also apply (e.g. copies exceeding 10 pages, cost of a Universal Serial Bus (USB) or retrieval fees related to offsite storage). If additional costs apply, you will be advised of the estimate of fees and asked to accept the estimate prior to processing this request.

*Where Visa, Mastercard or Interac is not accepted, payment can be made by cash or cheque made payable to Southern Health-Santé Sud.

This form is to be used only when a trustee is required to disclose PHI for a purpose that requires consent from the individual or a person permitted to exercise the rights of an individual.

You will be contacted if an administrative fee applies.

This form is to be used when an individual (a patient receiving health services from a hospital, client receiving community health services or a resident in a personal care home) requests a correction to their own PHI; or when a person permitted to exercise the rights of an individual requests a correction to PHI about the individual.

PART 1 – FOR MYSELF

Name*

First Middle Initial Last

Birthdate (dd-mm-yyyy)*

DD dash MM dash YYYY

Primary Phone*

Email Address*

Do you have a Manitoba PHI Number (PHIN)?*

Yes

No

Please enter your Manitoba PHI Number (PHIN)*

9-digit number on the Manitoba Health Card (no spaces)

Other Provincial / Territorial Health Insurance Number*

Your Address

Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

PART 1 – ON BEHALF OF ANOTHER INDIVIDUAL

Requestor's Name (You)

First Middle Initial Last

Your relationship to the individual

any person with written authorization from the individual to act on the individual’s behalf;

a proxy appointed by the individual under The Health Care Directives Act;

a committee appointed for the individual under The Mental Health Act if the committee has the power to make healthcare decisions on the individual’s behalf;

a substitute decision-maker for personal care appointed for the individual under The Vulnerable Persons Living with a Mental Disability Act if the exercise of the right relates to the powers and duties of the substitute decision-maker;

the parent or guardian of an individual who is a minor, if the minor does not have the capacity to make health-care decisions;

the personal representative if the individual is deceased;

other relationship

(select the appropriate)

Additional relationships to the individual

the individual’s spouse, or common-law partner, with whom the individual is cohabitating

a son or daughter

a parent, if the individual is an adult

a brother or sister

a person with whom the individual is known to have a close personal relationship

a grandparent

a grandchild

an aunt or uncle

a nephew or niece

File(s) Upload

Drop files here or Select files

Accepted file types: doc, docx, pdf, jpg, jpeg, gif, png, Max. file size: 5 MB, Max. files: 5.

provide a copy of the supporting documents that confirm your authority to act on behalf of the individual

Requester’s Primary Phone

Requester’s Email address

Requester’s Address

Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

Individual’s Name

First Middle Initial Last

Individual’s Birthdate (dd-mm-yyyy)

DD dash MM dash YYYY

Individual’s Primary Phone

Manitoba PHI Number (PHIN)?

Yes

No

Individual’s Manitoba PHI Number (PHIN)

9-digit number on the Manitoba Health Card

Individual’s Other Provincial / Territorial Health Insurance Number

The individual’s address is

same as requester

different from requester

unknown

Individual’s address

Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

PART 2 – HEALTH RECORDS

Health records may be kept at more than one site (clinic, hospital, program, etc.). Please provide information where the PHI is being requested.

Record(s) details*

Site / program name

Location

Date of visit (dd-mm-yyyy)

 

Add Remove

Specific PHI being requested*

Specific PHI being disclosed*

Specify to whom the PHI is to be disclosed.

Name of organization / individual*

Primary Phone*

Email address*

Specific correction to PHI being requested*

Notes

Requester’s e-signature*

Email

This field is for validation purposes and should be left unchanged.

Conduct Research Application

ORG.1810.PL.004.FORM.01

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Conduct Research Application

"*" indicates required fields

Title of project

Primary researcher(s)

Name

Title / Position

Tel #

Email

Town / City

Province

 

Add Remove

Brief summary / description of research project

Please include the research question as stated in the request.

Proposed date of commencement (dd-mm-yyyy)

DD dash MM dash YYYY

Proposed date of completion (dd-mm-yyyy)

DD dash MM dash YYYY

Location(s) where research will be conducted

e.g. specific hospital, personal care home, participant home, etc

Staff time is required in order for researcher to conduct the research?

Yes

No

The study has been

Approved

Denied

by an accredited ethics board.

The following staff are required

Program / Service

Est. # of hours required

Est. cost per hour

 

Add Remove

e.g. health records, nursing, social work, etc.

Other costs will be incurred?

e.g. lab tests, imaging, administrative such as telephone or stationery

Yes

No

Please upload the following required files:

– A copy of your current valid Research Ethics Board (REB) approval – A copy of approval letter from the Provincial Health Research Privacy Committee (PHRPC) – Participant Information – Participant Consent Form – Other relevant documentation supporting your research study (e.g. costs)

Drop files here or Select files

Accepted file types: xls, xlsx, doc, docx, pdf, Max. file size: 5 MB.

Consent*

1. not to publish the personal health information requested in a form that could reasonably be expected to identify the individuals concerned;
2. to use the personal health information requested solely for the purposes of the approved research project; and
3. to ensure that the research project complies with the safeguards and procedures, specifically the project shall contain:
a. reasonable safeguards to protect the confidentiality and security of the personal health information; and
b. procedures to destroy or remove, at the earliest opportunity consistent with the purposes of the research, any information that, either by itself or when combined with other information available to the holder, allows Individuals to be readily identified.
4. to provide the regional Ethics Committee Chair a minimum of five (5) business days notice prior to research publication or presentation.
5. this agreement shall continue following the completion of the approved research project.

I agree to the above.

Signature

Email

This field is for validation purposes and should be left unchanged.

Volunteer Application

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Volunteer Application

Step 1 of 5

20%

CONTACT INFORMATION

Name

First Middle Last

Phone

Email

Address

Street Address Town / City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

Are you 15 years of age or younger

Yes

No

Please tell us your age

Parent / Guardian Awareness: You will receive a printable PDF copy of this application via the email address specified. Please print this document and obtain the required guardian / parent signature.

EDUCATION

Not required to be a volunteer – we welcome experience of all kinds.

Are you currently a student?

Yes

No

School Name

Grade Level / Year of Study

Course of Study

Expected Date of Graduation (dd-mm-yyyy)

DD dash MM dash YYYY

Are you receiving credit for your volunteer work?

Yes

No

# of hours

By when? (dd-mm-yyyy)

DD dash MM dash YYYY

What is your highest level of education?

(please choose)High SchoolTrade / BusinessUniversity / CollegeOther

Degree / course of study

(please specify)

Other education level

(please specify)

EMPLOYMENT & VOLUNTEER HISTORY

Currently, I am…

(please choose)EmployedHomemakerRetiredStudentUnemployed

Company Name / Employer

(current or last)

Job title

(current or last)

Employed from (dd-mm-yyyy)

DD dash MM dash YYYY

Employed to (dd-mm-yyyy)

DD dash MM dash YYYY

Reason(s) for leaving

Volunteer Work

Organization

Time Period

Responsibilities

Reason(s) for leaving

 

Add Remove

List organizations in your community that you are involved with (incl. Community clubs, schools, religious organizations, professional associations, non-profit organizations, sporting organizations, etc.)

Have you ever volunteered with this organization before?

Yes

No

When were you a volunteer? (dd-mm-yyyy)

DD dash MM dash YYYY

Select the site where you want to volunteer

(please choose)Altona Community Memorial Health CentreBethesda PlaceBethesda Regional Health CentreBoundary Trails Health CentreBoyne Lodge Personal Care HomeCarman Memorial HospitalCentre de santé – Foyer Notre DameCentre de santé Notre Dame Health CentreCentre de santé St. Claude Health CentreCentre médico-social De Salaberry District Health CentreDouglas Campbell LodgeEastview PlaceEden Mental Health CentreEmerson Health CentreGladstone Health CentreHeritage Life Personal Care HomeHôpital Ste-Anne HospitalLions Prairie ManorLorne Memorial HospitalMacGregor Health CentreMenno Home for the AgedMorris General HospitalPembina Manitou Health CentrePortage District General HospitalPrairie View LodgeRed River Valley LodgeRepos JolysRest Haven Nursing HomeRock Lake Health District HospitalRock Lake Health District Personal Care HomeSalem Home Inc.Tabor Home Inc.Third Crossing ManorVilla Youville Inc.Vita & District Health CentreVita & District Personal Care Home

What skills and experience you have to offer?

(check all that apply)

Class 5 driver’s license

Clerical, organizational

Computer, technology

Experience with children/youth

Experience with elderly

Facilitation

Food handling / service

Fundraising experience

Health care

Languages

Public speaking

Recreation / coaching

Research

Training / education

Writing

Other

Other skills

(please specify)

What are your reason(s) for volunteering?

(check all that apply)

Academic credit

Employment experience

Explore careers

Increase self-esteem

Learn new skills

Help others

Improve health care

Social interaction

Relative / friend volunteers

Practice English skills

Stay active / involved

Other

Other reasons

(please specify)

How did you find out about our volunteer program?

Community

Employee of SH-SS

Info booth

Newspaper

Physician

Poster / brochure / flyer

Previously a patient / client

Previously a volunteer

Radio

Relative / friend

School

Volunteer

Website / Social Media

Other

(check all that apply)

Other source

(please specify)

AVAILABILITY

Select preferred time periods you are available to volunteer for the next three months. Specify times you would arrive/leave your shift.

Day(s) of the week

(choose all that apply)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Time of Day

(choose all that apply)

Morning

Afternoon

Evening

Arrival Time

Hours

:

Minutes

AM PM AM/PM

Departure Time

Hours

:

Minutes

AM PM AM/PM

How many shifts a week would you like to volunteer?

Are there times of the year that you are not available to volunteer?

Are you interested in volunteering for special projects or events?

Yes

No

Health Information

Please list any intellectual or physical disabilities or health problems which may affect your ability to perform as a volunteer and that you wish to have taken into considerations when determining a volunteer placement.

e-Signature

Parent / Guardian Awareness: You will receive a printable PDF copy of this application via the email address specified. Please print this document and obtain the required guardian / parent signature.

Phone

This field is for validation purposes and should be left unchanged.

After clicking on the ‘Submit’ button, you will see a page confirming that your submission has been received.

Indigenous Health Internship Program (IHIP)

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Indigenous Health Internship Program Application

Which internship program are you applying for?

Adult

High School

Name

First Last

Email

Home Phone

Work Phone

Mobile Phone

Do you have a Facebook account?

Yes

No

Facebook account profile

Address

Street Address Address Line 2 Town / City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

School / Institution

Location

Grade Level completed?

Year

How did you hear about the program?

another student

community centre

employment centre

flyer / poster

friend

Internet

newspaper

school

self-referral

workshop

other

Other (heard about program)

Employment background

Job Title

Employer

Tel

Start Date

End Date

 

Add Remove

Current cover letter and resume attached?

Yes

No

Cover letter and Resume upload

Accepted file types: pdf, doc, docx, rtf, txt, Max. file size: 5 MB.

Do you require any accommodations to perform job duties?

Yes

No

Please specify the accommodations needed

Describe your future career goals / ambitions

What type of health careers are you interested in learning about?

Southern Health-Santé Sud requests Indigenous people to self-identify by completing this voluntary self-declaration.

Treaty Status

(indicate which community you are a member of)

Inuit

Métis

Non-status

other

Community Name

(please specify)

Treaty Card #

Other treaty status

(please specify)

e-Signature

Comments

This field is for validation purposes and should be left unchanged.

General Inquiries

This general inquiry message system is only monitored during the hours of 8:30 am – 4:30 pm, Monday-Friday.
Please understand this is NOT an emergency help line.
For all appointment inquiries / cancellations / scheduling, please contact your clinic / doctor’s office.

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

We are committed to fostering a positive, respectful, and inclusive environment for everyone. As such, any form of disrespectful language, harassment, or bullying will not be tolerated. This includes, but is not limited to, offensive remarks, discriminatory behavior, threats, or any actions that create an unsafe or unwelcoming space.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

What Matters To You?

Southern Health-Santé Sud is on a continuous journey to put people first. When we think of moving forward as an organization, we envision doing it together, with you.

As a demonstration of our commitment to people-centred care and patient and public engagement, Southern Health-Santé Sud is integrating a health care movement that encourages health care providers to add one simple question to every interaction. This question is:  “What Matters to You?”

The goal of asking this question is to better understand the needs of our patients, residents, clients, family, stakeholders and community members and determine how to best address them together.

Taking part is easy, all you have to do is share what matters to you! Participating in a “What Matters to You?” conversation can take some thought and courage, but it’s a simple process. Just follow three steps:

Are you interested in further involvement?

We have several engagement opportunities based on your area of interest, lived experience and availability. Please complete the following form and you will be contacted to discuss relevant opportunities. If you would like to share your health care experience with us, please access the Compliments & Concerns page.

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Well Wishes

Well Wishes are designed to provide family and friends with convenient e-mail access to residents and patients who are in a Southern Health-Santé Sud facility. This email account is checked daily, except weekends and holidays. Messages will be delivered during business hours, Monday to Friday.

Please note that this service is available to extend only Well Wishes. For privacy reasons, a message sent for conducting topics of personal business or containing diagnoses and/or treatments, business / vendor solicitations or questionable content will not be delivered and will be deleted from the system. Messages received after the intended recipient has been discharged will also not be delivered.

To send Well Wishes, simply complete the form below and we will deliver your message to your loved one or friend.

Thank you for bringing a ray of sunshine to someone’s day!

Southern Health-Santé Sud does not accept Well Wishes for patients in Day Clinics, Day Surgery or Adult Emergency.

This form is available in alternate formats upon request. Please contact us by email or 1-800-742-6509.

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Sending Well Wishes to a Loved One

After clicking on the ‘Submit’ button, you will see a page confirming that your submission has been received.