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Home Care Policies & Forms

(also see Access, Service Delivery, Nursing, or Case Coordination)

Policy #TitleRationaleDateSummaryLink
CLI.5410.PL.007.SD.01.FClient Guidelines for Workplace Safety and Health-FROct 20, 2025
CLI.5410.PL.007.FORM.01Working Alone Safety Assessment Safe Visit PlanOct 20, 2025
CLI.5410.PL.007.SD.03Working Alone Safety Assessment and Safe Visit Plan Nurse SchedulerOct 20, 2025
CLI.5410.PL.007.FORM.02Safe Visit PlanOct 20, 2025
CLI.5410.PL.007Working Alone Safety AssessmentOct 20, 2025
CLI.5410.PL.007.SD.02Working Alone Safety Assessment and Safe Visit Plan Resource Coordinator and Scheduling ClerkOct 20, 2025
CLI.5410.PL.007.SD.01Client Guidelines for Workplace Safety and HealthOct 20, 2025
Home Care Treatment Clinic Billing FormOct 20, 2025
Advanced Glucose Monitors in the Home Care SettingSep 15, 2025
CLI.5410.PL.003.FORM.05Home Care Referral Intake LogJun 9, 2025
CLI.5410.PL.003Home Care Referral and Intake Process for Home Care ServicesJun 9, 2025
CLI.5410.PL.003.FORM.04Home Care Referral and Intake Process Home Care Treatment Clinic ReferralJun 9, 2025
CLI.5414.SG.001Home Care Attendant Timekeeping Balance SheetJun 2, 2025
CLI.5414.SG.001Storage of Home Care Attendant Timesheets Balance SheetsJun 2, 2025
CLI.5410.PL.004Eligibility for Home CareMar 31, 2025
Medical Assessment for LTC FormMar 3, 2025
CLI.5410.PL.006.SD.01Home Care Smoking Vaping Cigarette Cigar and eCigarette – BilingualFeb 10, 2025
CLI.5410.PL.005.SD.01Home Care Smoking Cannabis for Medical PurposesFeb 10, 2025
CLI.5413.SG.001.FORM.03Re Assessment Form for Long Term Care ApplicantsJan 31, 2025
CLI.5413.SG.001Assessment and Application Process for Personal Care Home Supportive Housing and Chronic CareJan 31, 2025
CLI.5413.FORM.002.FPrivate Seniors Living Residences FAQs FRJan 24, 2025
CLI.5413.FORM.002Private Seniors Living Residences FAQsJan 24, 2025
CLI.5413.FORM.001.FGuidelines for Private Seniors Living Residences FRJan 24, 2025
CLI.5413.FORM.001Guidelines for Private Seniors Living ResidencesJan 24, 2025
CLI.5413.SG.001.Form.01Application Assessment for LTC Panel Presentation FormJan 17, 2025
CLI.5413.SG.001.Form.02Application for Personal Care Home ChecklistJan 17, 2025
CLI.5412.SG.003.FORM.01Vitamin B12 Injection FormDec 11, 2024
CLI.5412.SG.003Vitamin B12 InjectionDec 11, 2024
CLI.5411.PL.010Nursing Service DeliveryFeb 27, 2023
CLI.5411.PL.010.SD.01Nursing Service Delivery Info SheetFeb 27, 2023
CLI.5412.PL.01.SD.01HC Wound Photography Flow ChartFeb 22, 2023
CLI.5412.PL.001Wound Care Management by Client CaregiverFeb 22, 2023
CLI.5411.PL.011.FORM.01Seating Cushions Covers Client InfoFeb 21, 2023
CLI.5410.SG.001.SD.01Home Care Alternate Access to HomeFeb 21, 2023
CLI.5410.SG.001Alternate Access to HomeFeb 21, 2023
CLI.5411.PL.011Seating Cushions CoversFeb 21, 2023
CLI.5412.SG.001.SD.01HC Collaborative Care Team Meeting Ground RulesJun 12, 2022
CLI.5412.SG.001.FORM.01HC Collaborative Care Team Action LogJun 12, 2022
CLI.5412.SG.001Home Care Client Collaborative Care ModelJun 12, 2022
CLI.5413.SG.003Back Up Plan for Service InterruptionMay 3, 2022
CLI.5413.SG.003.SD.01Back Up Plan Client InfoMay 3, 2022
CLI.5415.PL.002Animals Pets in the Home and AreasMar 31, 2022
CLI.5411.PL.009.FORM.03Client Home Care Standard Agreement TemplateMar 31, 2022
CLI.5411.PL.009.SD.01Client Home Care Standard Agreement Template ExampleMar 31, 2022
CLI.5411.PL.009.FORM.01Suspension of Home Care Services Letter TemplateMar 31, 2022
CLI.5411.PL.009.FORM.01.FSuspension of Home Care Services Letter Template – FrenchMar 31, 2022
CLI.5411.PL.009.FORM.02Withdrawal of Home Care Services Letter TemplateMar 31, 2022
CLI.5411.PL.009.FORM.02.FWithdrawal of Home Care Services Letter Template – FrenchMar 31, 2022
CLI.5411.PL.009Interruption of Home Care ServicesMar 31, 2022
CLI.5415.PL.002.FORM.01Home Care Animals Pets Information SheetFeb 3, 2022
CLI.5415.PL.002.FORM.01.FHome Care Animals Pets Information Sheet – FrenchFeb 3, 2022
CLI.5411.PL.008.FORM.01Home Care Assigned Task Training RequestJan 24, 2022
CLI.5411.PL.008.FORM.03Home Care Assigned Task Monitoring RecordJan 24, 2022
CLI.5411.PL.008.FORM.02Home Care Attendant Ride Along ObservationJan 24, 2022
CLI.5411.PL.008Home Care Assignment of Tasks to Home Care AttendantsJan 24, 2022
CLI.5411.PL.008.SD.01Southern Health Sante Sud Assigned Task ListJan 24, 2022
CLI.5410.SG.003.FORM.01Application for Community Urgent StatusNov 8, 2021
CLI.5410.SG.003.FORM.02Termination for Community Urgent StatusNov 8, 2021
CLI.5410.SG.003Home Care Services Community UrgentNov 1, 2021
CLI.5410.PL.006Home Care Smoking Vaping Cigarette Cigar and eCigarette in the HomeJul 30, 2021
CLI.5410.PL.005Policy Cannabis for Medical Purposes in the HomeJul 6, 2021
CLI.5411.SG.007.SD.01Home Care Client Information Sheet SuppliesSep 29, 2019
CLI.5415.PL.001.FORM.01SBAR Clinical Home CareJun 26, 2019
CLI.5411.SG.002.SD.01Home Care Client Information Sheet Mobility Exercise Transfer PositioningMay 23, 2019
CLI.5411.SG.002Home Care Services Mobility Exercise and Transfer PositioningMar 15, 2019
CLI.5411.SG.001.SD.02Home Care Client Information Sheet Household Maintenance and LaundryMar 15, 2019
CLI.5411.SG.009.SD.02Home Care Client Information Sheet Personal Care and HygieneMar 15, 2019
CLI.5411.SG.006.SD.01Home Care Client Information Sheet EquipmentMar 15, 2019
CLI.5411.SG.008.SD.01Home Care Client Information Sheet Meal PreparationMar 15, 2019
CLI.5411.PL.007.SD.01.FHome Care Information Pamphlet – FrenchMar 15, 2019
CLI.5411.PL.007Home Care ServiceMar 15, 2019
CLI.5411.SG.001.SD.01Case Coordinator Considerations Household Maintenance and LaundrySep 29, 2018
CLI.5411.SG.005.SD.02Case Coordinator Service Considerations EliminationSep 29, 2018
CLI.5411.SG.007Home Care Services SuppliesSep 29, 2018
CLI.5411.SG.009Home Care Services Personal Care and HygieneSep 29, 2018
CLI.5411.SG.001Home Care Services Household Maintenance and LaundrySep 29, 2018
CLI.5411.SG.005.SD.01Home Care Client Information Sheet EliminationSep 29, 2018
CLI.5411.SG.006Home Care Service EquipmentSep 29, 2018
CLI.5411.SG.006.SD.02Responsibility For Payment for Equipment and SuppliesSep 29, 2018
CLI.5411.SG.005Home Care Services EliminationSep 29, 2018
CLI.5411.SG.009.SD.01Case Coordination Service Considerations Personal CareSep 28, 2018
CLI.5411.SG.010.SD.01Case Coordinator Considerations Oral Feeding without Swallowing DisorderSep 28, 2018
CLI.5411.SG.003.SD.01Case Coordinator Service Consideration for Respite Care in the HomeSep 28, 2018
CLI.5411.SG.003Home Care Services Respite Care In the HomeSep 28, 2018
CLI.5411.SG.004Home Care Services Off Site ServiceSep 28, 2018
CLI.5411.SG.008Home Care Services Meal PreparationSep 28, 2018
CLI.5411.SG.008.SD.02Home Care Case Coordinator Service Considerations Meal PreparationSep 28, 2018
CLI.5411.PL.007.SD.01Home Care Information BookletSep 28, 2018
CLI.5411.SG.010Oral Feeding without Swallowing DisorderSep 28, 2018
CLI.5415.PL.001.FORM.02Home Care Transfer Form Agency to AgencyJun 20, 2018
CLI.5415.PL.001Information Transfer at Care Transition Home CareJun 20, 2018
CLI.5411.PL.006.FORM.04Home Oxygen Concentrator Program Blinded Six 6 Minute Walk TestMar 31, 2018
CLI.5411.PL.006.FORM.03Home Oxygen Concentrator Program Safety Information RequirementsMar 30, 2018
CLI.5411.PL.006.FORM.02Home Oxygen Concentrator Program Request for Removal of ServiceMar 30, 2018
CLI.5411.PL.006.FORM.01Home Oxygen Concentrator Program Medical Assessment Referral FormMar 30, 2018
CLI.5411.PL.006Home Oxygen Concentrator ProgramMar 30, 2018
CLI.5411.PL.006.SD.01Home Oxygen Concentrator Program HOCP Referral Pathyway Acute Community PalliativeMar 30, 2018
CLI.5410.PL.003.FORM.02Home Care Referral and Intake Process Home Care Referral HospitalJan 25, 2018
CLI.5410.PL.003.FORM.03Home Care Referral and Intake MB HC Program Short Term Assessment Hospital Discharge Form and Basic Information FormJan 25, 2018
CLI.5410.PL.003.FORM.01Home Care Referral and Intake Process Manitoba Home Care Program Basic InformationJan 25, 2018
CLI.5410.PL.001.FORM.01Violence Prevention Program and Safe Visit Plan VPP Screening Treatment ClinicJun 16, 2017
CLI.5410.PL.001Violence Prevention Program Home CareJun 16, 2017
CLI.5411.PL.005.FORM.01Facility Respite Admission Agreement TemplateMay 23, 2017
CLI.5411.PL.005.FORM.01.FFacility Respite Admission Agreement Template – FrenchMay 23, 2017
CLI.5411.PL.005.FORM.02Respite Care in a Designated Respite Bed ReferralMay 23, 2017
CLI.5411.PL.005.FORM.03Respite Care in a Designated Respite Bed Physicians Notification and Standing OrdersMay 23, 2017
CLI.5411.PL.005.FORM.04Respite Care in a Designated Respite Bed CommunicationMay 23, 2017
CLI.5411.PL.005Respite Care Home and FacilityMay 23, 2017
CLI.5413.PL.001Falls Prevention and ManagementFeb 10, 2017
CLI.5413.PL.001.SD.05Falls Prevention A Checklist for You and Your FamilyFeb 10, 2017
CLI.5413.PL.001.SD.05.FFalls Prevention A Checklist for You and Your Family – FrenchFeb 10, 2017
CLI.5411.PL.003Client Level of RiskFeb 10, 2017
CLI.5411.PL.001.FORM.02Home Care Special Approval Over Service Over Protocol RequestFeb 10, 2017
CLI.5411.PL.001Home Care Special Approval Over Service Limit PolicyFeb 10, 2017
CLI.5413.PL.001.FORM.01Home Care Falls Risk Assessment ToolFeb 10, 2017
CLI.5413.PL.001.SD.02Home Care Regional Post Falls Response AlgorithmFeb 10, 2017
CLI.5411.PL.003.FORM.01Risk Assessment Tool for Home Care ClientsFeb 10, 2017
CLI.5413.PL.001.SD.03Public Agency of Canada Fact Sheet You Can Prevent FallsFeb 10, 2017
CLI.5413.PL.001.SD.04Public Agency of Canada Fact Sheet 12 Steps to Stair Safety at HomeFeb 10, 2017
CLI.5413.PL.001.SD.04.FPublic Agency of Canada Fact Sheet 12 Steps to Stair Safety at Home – FrenchFeb 10, 2017
CLI.5413.PL.001.FORM.02Required Home Care Falls Prevention and Management Intervention ChecklistFeb 10, 2017
CLI.5413.PL.001.SD.03.FPublic Agency of Canada Fact Sheet You Can Prevent Falls – FrenchFeb 10, 2017
CLI.5411.PL.004Emergency PanelJan 23, 2017
CLI.5410.PL.002.SD.01Supportive Housing Discharge CriteriaJan 23, 2017
CLI.5410.PL.002.SD.02Specialized Personal Care Home Environments DescriptorsJan 23, 2017
CLI.5410.PL.002Personal Care Home and Supportive Housing ApplicationJan 23, 2017
CLI.5413.PL.001.SD.01Home Care Falls Prevention and Management AlgorithmMay 12, 2016
CLI.5411.PL.002Client Not Home for a Scheduled Home Care VisitApr 19, 2016
CLI.5411.PL.002.SD.01Client Not Home for a Scheduled Visit Intervention AlgorithmApr 19, 2016
CLI.5411.PL.002.SD.02Quick Reference Guide Client Not Home for a Scheduled Visit Factors to Consider in Decision MakingApr 19, 2016
CLI.5411.PL.001.FORM.01Home Care Over Service Limit Calculation ToolAug 13, 2015

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