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Agency Policies and Procedures - Table of Contents

Defines the various types of policy statements guiding actions and practice within the organization including how these statements are developed and approved. Also includes information of relevance to the interpretation of policy statements.

Policy #	Policy Description	Date Approved
GEN0101	Policy Authority, Distribution and Change	September 20, 2020
GEN0102	Definitions	March 1, 1998
GEN0103	Guidebooks	February 25, 2015
GEN0104	Protocol and Guideline	June 8, 2011
GEN0105	Directives and Standing Orders	August 25, 2010
GEN0106	Committee Form & Function	October 22, 2024
GEN0107	Emergency Response	September 25, 2013
GEN0108	Emergency Fan- Out Notification System Policy	January 9, 2013

Sets expectations for employee behaviour where organizational values dictate the acceptable code of conduct. Includes process for performance review, conflict of interest, fund raising and attendance.

Policy #	Policy Name	Date Approved/Latest Update
HR0101	Employee Conduct	September 30, 2020
HR0102	Conflict of Interest	September 9, 2020
HR0103	Acceptance of Gifts, Donations and Honoraria	October 7, 2020
HR0104	Gambling Activities for Fund Raising	September 9, 2020
HR0105	Performance Review	August 9, 2023
HR0108	Alcohol Recreational Cannabis and Unregulated and Regulated Drug Use Policy	August 30, 2024

Defines the parameters for recruitment, hiring, termination and related information management.

Policy #	Policy Name	Date Approved/Latest Update
HR0201	Employee Classification	August 9, 2023
HR0202	Recruitment, Selection and Hiring	March 9, 2022
HR0203	Staff Qualifications	December 14, 2007
HR0204	Employment Files	October 7, 2020
HR0205	Non-Union Employee Seniority	May 5, 2021
HR0207	Termination Compensation	February 8, 2017
HR0208	Resignation & Retirement	October 14, 2020
HR0209	Student and Volunteer Placements	June 2, 2021
HR0210	Employment Background Check	June 23, 2021
HR0211	Appointment of the Leadership Designate Role	February 29, 2024
HR0212	Non Union Non Management Lay Off and Bumping	May 12, 2021

Defines the parameters for years of service, collective agreement, grievance procedure, flower donation requests, and staff attendance at board meetings.

Grievance Procedure for Non-Union and Managerial Staff

Policy #	Policy Name	Date approved/Latest Update
HR0301	Employee Recognition	August 25, 2021
HR0302	Negotiation and Ratification of Collective Agreements	August 25, 2021
HR0303	Flower/Donation Requests	June 2, 2021
HR0305	Grievance Procedure for Non-union and Mgmt Staff	January 8, 2020

Defines the parameters and the procedures related to employee compensation and payroll.

Policy #	Policy Name	Date Approved/Latest Update
HR0401	Position Descriptions	February 20, 2025
HR0402	Job Evaluation Non-Union Positions	February 20, 2025
HR0403	Payroll	September 29, 2022
HR0404	United Way Payroll Deduction Program	August 25, 2021
HR0405	Salary Determination	August 9, 2023

Defines the parameters for benefits administration, OMERS administration and Employee Assistance.

Policy#	Policy Name	Date Approved/Latest Update
HR0501	Employee Benefits	August 9, 2023
HR0503	Vision Care	May 8, 2024
HR0504	Liability Insurance	February 9, 2011
HR0506	Access to Smoking and Vaping Cessation Supports	April 24, 2025

Defines the parameters that address the hours than an employee works.

Policy #	Policy Name	Date of Approval/Latest Update
HR0601	Hours of Work	August 30, 2023
HR0602	Paid Rest Periods	January 10, 2024
HR0603	Flexible Working Hours	February 23, 2022
HR0604	Flexible Working Hours for Managerial Staff	April 25, 2024
HR0605	Disconnecting From Work: Non-Managerial Employees	June 2, 2022
HR0606	Disconnecting From Work: Managerial Employees	June 2, 2022

Defines the parameters that address employee holiday, vacation, and leaves.

Policy#	Policy Name	Date of Approval/Latest Update
HR0701	Vacation	August 30, 2023
HR0702	Statutory Holidays	August 22, 2021
HR0703	Family Related Leave	August 30, 2023
HR0704	Sick Leave	August 30, 2023
HR0705	Bereavement Leave	May 4, 2022
HR0707	Pregnancy, Parental and/or Adoption Leave	November 27, 2019
HR0708	Leave of Absence (paid)	May 11, 2022
HR0709	Leave of Absence (unpaid)	November 9, 2022
HR0710	Court Attendance	July 6, 2022
HR0711	Winters Season Office Closures	September 16, 2009
HR0712	Pre-Paid Leave of Absence	November 9, 2022

Defines the parameters and includes all aspects of employee growth and development including orientation, inservicing, mentoring, succession planning.

Policy #	Policy Name	Date Approved/Latest Update
HR0801	New Employee Orientation and Onboarding	November 9, 2022
HR0802	Professional Development	July 6, 2022
HR0803	Out of Province and Out of County Travel	October 12, 2022

Define the parameters for office use, office closure, alternative office settings and incident response.

Policy #	Policy Name	Date Approved/Latest Update
OP0102	Use of Rooms for Non-Health Unit Activities	February 29, 2024
OP0103	Smoke and Vapour-Free Offices Policy	April 24, 2025
OP0104	Office Closure	August 30, 2023
OP0107	Response to Health Unit Vaccine Fridge Alarms	March 11, 2024
OP0108	Hybrid Office	December 14, 2022
OP0109	Vehicle Idling	November 9, 2022
OP0110	Work from Home Policy	August 9, 2023
OP0112	Response to Unusual Events In and Around SMDHU Offices	January 22, 2025

Define parameters and legislative requirements, in addition includes policies that support and encourage employee health in the broadest sense.

Policy #	Policy Name	Date Approved/Latest Update
HS0101	Agency Health and Safety Policy	June 28, 2023
HS0102	Staff Exposure to Blood and Body Fluids	April 30, 2020
HS0103	Electrical Safety and Maintenance	October 5, 2022
HS0104	Slips Trips and Falls	January 12, 2005
HS0105	Injury/Illness While in the Course of Employment: WSIB	October 12, 2022
HS0106	Influenza Immunization	June 10, 2015
HS0107	Employee Immunization Policy	February 27,2025
HS0109	Workplace Violence and Prevention	October 12, 2022
HS0110	Protection From Second Hand Smoke and E-Cigarette Vapour	January 24, 2018
HS0111	Creating a Supportive Workplace Food Environment	May 24, 2023
HS0112	Harassment Response Policy and Program	October 26, 2022
HS0113	Joint Health and Safety Committee	October 12, 2022
HS0114	Motor Vehicle Incident Prevention	April 25, 2018
HS0115	Breastfeeding Friendly Workplace	October 26, 2016
HS0116	Use of Safety-Engineered Needles	September 28, 2011
HS0117	Early and Safe Return to Work	October 5, 2022
HS0118	Infection Prevention and Control: Routine Practices and Additional Precautions	February 25, 2015
HS0119	Cleaning and Disinfection of Non-Critical Multi-Use Device / Equipment	May 27, 2015
HS0120	Hand Hygiene	May 27, 2015
HS0121	Early and Safe Return to Work for Non-Work Related Illness or Injury	June 23, 2021
HS0122	COVID-19 Vaccination	October 24, 2024

Define parameters for information privacy and access, documentation, and records management.

Transporting Records Policy Transporting Records Policy Transporting Records Policy

Policy #	Policy Name	Late of Approval/Latest Update
IM0101	Personal Health Information Privacy Policy	September 24, 2020
IM0108	Information Privacy and Security Incident Management Policy	September 24, 2020
IM0109	Documentation of Client Care and /or Services	April 10, 2024
IM0110	Records Management	November 24, 2003
IM0111	Contact Management	February 2, 2022
IM0113	Library Services	August 23, 2000
IM0117	Use of Electronic Signatures	October 22, 2008
IM0119	Information Privacy and Security Assessment	September 23, 2009
IM0120	Fax Policy	May 28, 2014
IM0121	Transporting Records Policy	February 11, 2020
IM0122	Virtual Meetings using Microsoft Teams	May 4, 2022
IM0123	Electronic Document Imaging (EDI) Policy	September 29, 2022

Define parameters for communications with the public and other stakeholders (external communications) in order to ensure efficiency, effectiveness, quality and consistency.

Policy #	Policy Name	Date of Approval/Latest Update
PR0101	Media Relations and Communications	July 24, 2007
PR0102	Copyright	October,5 2022
PR0103	Use of Health Unit Logo	October 22, 2024
PR0104	French Translation	July 7, 1999
PR0105	Resource Production Distribution & Ordering	October 20, 2010
PR0106	Social Media	August 29, 2018

Define the parameters for obtaining funding, expending agency funds, purchasing required equipment and clothing and for claiming expenses incurred while on agency business in order to ensure integrity and financial controls.

Policy #	Policy Name	Date of Approval/Latest Update
FI0101	Travel Conservation and Reimbursement	October 25, 2023
FI0102	Meal Allowance	June 23, 2021
FI0103	Protective Clothing and Equipment	March 24, 2024
FI0104	Expense Report	March 3, 2010
FI0105	Office Supply and Equipment Requisition	September 25, 1996
FI0106	Petty Cash	October 12, 2016
FI0107	Procurement Policy	March 16, 2016
FI0108	Corporate Sponsorship	September 29, 2004
FI0109	Involvement with External Applications for Funding	July 7, 1999
FI0110	Asset Capitalization Policy	November 18, 2015
FI0111	Use of Agency Credit Cards and Purchasing Cards	October 12, 2016
FI0112	Surplus Tangible Asset Management	October 27, 2021

Defines parameters for access and use of agency technology and resources.

Policy #	Policy Name	Date of Approval/Latest Update
TQ0101	Electronic Monitoring and Acceptable Use of SMDHU IT Equipment	August 24, 2022
TQ0102	Systems Access and Changes Including Email and Voicemail	July 17, 2000
TQ0103	Email and Voicemail Access from Home	March 5, 2008
TQ0104	Remote Access to Agency Network	March 5, 2008
TQ0105	Internet Policy and Guidelines	July 12, 2000
TQ0107	Use of Portable Electronic Storage Devices	November 30, 2005
TQ0108	Cell Phones and Other Mobile Communication Devices Deployment and Use	November 9, 2016
TQ0109	Agency Leased and Owned Vehicle Use	April 25, 2019
TQ0110	Personal Use of Health Unit Equipment & Services	March 3, 2010
TQ0111	Text Messaging SMDHU Clients	September 24, 2014
TQ0112	SMDHU and Artificial Intelligence Proper Use of Generative AI and Machine Learning Applications	January 10, 2024

Defines agency expectations for planning to be applied within all programs and services.

Policy #	Policy Name	Date Approved/Latest Update
PP0102	Operational Plans	August 12, 2009
PP0103	Public Health Research, Planning, Approval & Conduct	January 24, 2024
PP0104	Data Collection Policy	January 24, 2024
PP0105	Request for Service from External Clients	May 11, 2011
PP0107	Baby Friendly Initiative	September 7, 2017
PP0108	Accessible Client Service	February 7, 2017
PP0109	SMDHU Internal Process: Emergency Response to an Opioid Overdose/Poisoning	September 27, 2023

Defines parameters for action that are legally mandated or defined within professional standards of practice.

Policy #	Policy Name	Date of Approval/Latest Update
LG0101	Consent for Treatment	June 26, 1996
LG0102	Report to a Child Protection Agency	March 6, 2024
LG0103	Reporting of Medication Errors and Near Miss Policy	August 29, 2018
LG0104	Delegation of Controlled Acts	August 25, 2010
LG0105	Provincial Offenses Act Part III	November 22, 2000
LG0106	Mandatory Blood Testing for Blood Borne Disease	February 11, 2015
LG0107	Designation of Provincial Offenses Officer	November 22, 2000
LG0108	Commissioner for Taking Affidavits	November 22, 2000
LG0109	Corporate and Business Searches	November 22, 2000
LG0110	Title Searches	November 22, 2000

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Agency Policies and Procedures - Table of Contents

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