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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

June 8, 2011

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 Cannabis and Drug Use Policy

November 28, 2018

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 BumpingMay 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

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

July 13, 2022

HR0402

Job Evaluation

August 17, 2022

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 Tobacco Cessation Supports

February 11, 2020

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
HR0605Disconnecting From Work:  Non-Managerial EmployeesJune 2, 2022
HR0606Disconnecting 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 Vape-Free Offices Policy

October 25, 2017

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

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

Staff Immunization Recommendations

May 10, 2000

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
HS0121Early and Safe Return to Work for Non-Work Related Illness or Injury June 23, 2021
HS0122

COVID-19 Vaccination

 October 24, 2023

SMDHU policy HSO122 COVID-19 Vaccination Policy has been temporarily suspended and is therefore not in effect while SMDHU awaits the provincial COVID-19 vaccination recommendations for the Fall of 2024.

Notwithstanding, in order to protect the Health and Safety of both our staff and the clients we serve, all new hires and student placements are required to provide prior to the commencement date of their employment / placement either:  1 - satisfactory proof of up-to-date vaccination (an individual is "up to date" on their vaccinations if they have received all doses recommended by the Ontario Ministry of Health): or 2 - satisfactory documentation and proof of a valid medical exemption or other valid accommodation entitlement under the Ontario Human Rights Code.  SMDHU will then determine if the requested accommodation can be provided without undue hardship.

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

Transporting Records PolicyTransporting Records PolicyTransporting 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, 2008

PR0104

French Translation

July 7, 1999

PR0105

Resource Production Distribution & Ordering

October 20, 2010
PR0106Social MediaAugust 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

Clothing & Equipment (Health Unit Supplied)

September 25, 1996

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
FI0112Surplus 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
PP0109SMDHU Internal Process:  Emergency Response to an Opioid Overdose/PoisoningSeptember 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

LG0111

Smoker’s Helpline Fax Referral

February 8, 2017
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