Ontario Workplace Naloxone Program Application Eligible Employer InformationEmployer / Workplace / Business Name(Required) Address(Required) Street Address Address Line 2 City Postal Code Business Type by 2-Digit NAICs Code(Required)11 Agriculture, forestry, fishing and hunting21 Mining, quarrying, and oil and gas extraction22 Utilities23 Construction31-33 Manufacturing41 Wholesale trade44-45 Retail trade48-49 Transportation and warehousing51 Information and cultural industries52 Finance and insurance53 Real estate and rental and leasing54 Professional, scientific and technical services55 Management of companies and enterprises56 Administrative and support, waste management and remediation services61 Educational services62 Health care and social assistance71 Arts, entertainment and recreation72 Accommodation and food services81 Other services (except public administration)91 Public administrationWorkplace Size(Required)< 2020 - 4950 - 99100 - 499> 500Select the number of employees at this eligible workplace.Learner InformationYou are eligible to get free training for a maximum of two workers. There will be a fee for additional employees / learners for naloxone training.Employee / Learner #1(Required) First Last Employee / Learner #1 Email(Required) Employee / Learner #1 Training Type(Required) Online Only e-Learning Employee / Learner #1 Training Date(Required)December 15, 2023 2:00PM - 4:00PMEmployee / Learner #1 Virtual Training Date(Required)December 12, 2023 6:00PM - 8:00PMEmployee / Learner #1 Virtual Training Date(Required)December 12, 2023 6:00PM - 8:00PMEmployee / Learner #2 First Last Employee / Learner #2 Email Employee / Learner #2 Training Type Online Only e-Learning Employee / Learner #2 Training Date(Required)December 15, 2023 2:00PM - 4:00PMEmployee / Learner #2 Virtual Training Date(Required)December 12, 2023 6:00PM - 8:00PMContact PersonName of Eligible Employer Contact Person(Required) First Last Email(Required) Phone(Required)Attestation(Required)I, the contact person mentioned above, on behalf of the employer mentioned above, and for the workplace mentioned above, confirm that: I am authorized on behalf of the above-mentioned company to submit this registration and to bind them to the information I have provided. The above-mentioned company is an Eligible Employer. This workplace location is an Eligible Workplace.This workplace has a risk of at least one of our employees having an opioid overdose. This workplace location has not previously been registered for or received workplace naloxone trainingthrough Ontario’s Workplace Naloxone Program. The worker/s registered for training herein has/have not previously received free workplace naloxone training through Ontario’s Workplace Naloxone Program. I consent to the collection, use and disclosure of aggregate data related to business type, workplace size, and business postal code, as well as anonymized learner training evaluation results to the Ministry and its third-party service providers for the purposes of program evaluation and processing registration. All the information provided to the program provider is true, correct, and complete. If the information provided is found to be false or fraudulent, the program provider reserves all of its rights and remedies. I confirm my attestation above.Privacy StatementAs part of program administration and evaluation of the provision of free naloxone training to Eligible Employers through Ontario’s Workplace Naloxone Program, data related to business type, workplace size, and business postal code, as well as anonymized learner training evaluation results, will be collected and disclosed in aggregate to the Ministry of Labour, Immigration, Training and Skills Development (the “Ministry”) and its third-party service providers. The Ministry or its auditors may also request the records of SAJE Vital Signs related to the Program for audit purposes, including, without limitation, requesting copies of the attestations provided by registrants. By proceeding with registering for this naloxone training, you hereby consent to the collection, use and disclosure of such information, by and to the Ministry, its auditors and its third-party service providers for the purposes set out above. Any questions about the collection, use, and disclosure of information for the Workplace Naloxone Program by the Ministry can be directed to the Training and Awareness Branch, Prevention Division, Ministry of Labour, Immigration, Training and Skills Development by email at PreventionFeedback@ontario.ca or by phone at 1-416-212-9871. If you have any questions about SAJE Vital Sign's naloxone training, please email us at naloxone@vitalsigns.ca or call us at 800-461-7716. 62373
