Personal Service Setting Special Event Vendor Notification Form - Leeds, Grenville and Lanark District Health Unit

Name of Event(Required)

Location of Event(Required)

Date of Event(Required)

Business Information

Business Name(Required)

Owner/Operator Information

Primary Phone Number(Required)

Cell Phone Number(Required)

Email Address(Required)

Alternate Contact

Alternate Contact Phone Number

Alternate Contact Cell Phone Number

Alternate Contact Email Address

Event Information

Types of Services I Will Be Offering at the Event

Other Invasive Procedure(Required)

Other Non-Invasive Procedure(Required)

Instruments and Sterilization

Reprocessing/sterilization of instruments is not permitted onsite. It is recommended to use instruments that are single-use disposable and to bring multiple instrument sets for service onsite.

Other Non-Invasive Services Enclosure(Required)

Other Flooring(Required)

Cleaning and Waste Disposal

Any re-usable item will be placed into a puncture-resistant, leak proof container immediately after use. The container will be labelled 'Dirty Items - do not use'. These items will be brought back to the business location for proper cleaning and disinfection.

Hand Hygiene

All personal service workers must perform hand hygiene before service delivery and as required during and after service.

Client Vendor Health and Safety

Additional Comments

Personal Information

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c. H.7 as amended under Section 16 (2) and will be used for the administration and enforcement of the Food Premises Regulation. Questions concerning collection of this information should be directed to the Privacy Officer of the Leeds, Grenville and Lanark District Health Unit at 458 Laurier Blvd., Brockville, Ontario, K6V 7A3 [email protected] or 1-800-660-5853.

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