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  • Common Banks
    Title Payroll
    Location Finance, various departments
    Legal Authority Consent of individuals and as necessary to the proper administration of payroll for employees
    Information Maintained Name, address, SIN, benefits, tax contributions, pension contributions, employee salaries, deductions, time away, banking information, paid hours
    Uses Long and short term fiscal planning,
    Users Management
    Individuals in Bank Employees, previous employees
    Retention & Disposal 7 Years
  • Common Banks Personnel Files
    Title Personnel Files
    Location Human Resources, various management offices
    Legal Authority Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters
    Information Maintained Names, date of birth, contact information, education information, Opinions about performance, assessments, evaluations, time off requests, emergency contacts, job applications information, resumes, grievance information, criminal record checks, pension and benefit data, WSIB records, disciplinary actions, employment history, marital status, attendance and leave information, employment contracts, designated substance exposure records
    Uses Human Resources program administration, departmental management
    Users Human Resources staff, managers
    Individuals in Bank Employees, paid students, post-doctoral and research fellows, retirees
    Retention & Disposal 3 years after creation date for general employment records, 40 years for occupational health and safety, and workplace safety and insurance records.
  • Common Banks Event Tracking Reports
    Title Event Tracking Reports
    Location Quality Safety & Best Practice, various management offices
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), as necessary to the proper administration of risk management program
    Information Maintained Name, date of birth, contact information, communication related to event, details and description of the event, action plans
    Uses Event investigation and resolution
    Users Patient Safety Officer & Risk Manager; Director, Quality, Safety & Best Practice; Appropriate Leadership
    Individuals in Bank Employees, volunteers, students, clients, family members
    Retention & Disposal Until follow-up complete plus 2 years
  • Corporate Services Artists Information
    Title Artist information
    Location Culture, Arts & Innovation administration
    Legal Authority Consent of individuals and as necessary to the proper administration of the art collection.
    Information Maintained Names, contact information, tax receipts, correspondence
    Uses For collection/retention of art
    Users Art Administrator
    Individuals in Bank Artists who have donated works to Baycrest
    Retention & Disposal 1 year after date of last use
  • Corporate Services Music therapy client records
    Title Music therapy client records
    Location Music Therapy
    Legal Authority Consent of individuals
    Information Maintained Names, medical history, consent for video/audio recording, referrals
    Uses Provision of care to patients
    Users Music Therapist
    Individuals in Bank Apotex residents, hospital patients, clients of the Day Centre for Seniors
    Retention & Disposal 10 years after discharge or death
  • Education Student placement registration
    Title Student placement registration
    Location Academic Education
    Legal Authority Consent of individuals,  Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75, and as necessary to the proper administration of student education
    Information Maintained Name, discipline, contact information, emergency contacts, educational , institution, program, student number, evaluations, testimonials, criminal reference checks, immunization information.
    Uses To administer student placements
    Users Student Placement Coordinator
    Individuals in Bank Students
    Retention & Disposal 1 year after date of last use
  • eHealth Patient Record (paper chart and meditech)
    Title Patient Record (paper chart and meditech)
    Location Health Records
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2)
    Information Maintained Name, names of substitute decision maker, OHIP number, contact information, age, ethnic origin, marital status, test results, prescriptions, diagnoses, religion, status, medical opinions, plan of care, billing information
    Uses Record of care
    Users Individuals in a patient’s circle of care, health records staff
    Individuals in Bank Patients
    Retention & Disposal 10 years after discharge or death
  • eHealth Death Registry Logs
    Location Health Records
    Legal Authority  Necessary to the proper administration of a health facility
    Information Maintained Name of patient, cause of death, date and place of death
    Uses Reports deaths
    Users Nursing staff, Health Records staff,
    Individuals in Bank Previous patients
    Retention & Disposal 10 years after discharge or death
  • eHealth Access and Privacy tracking information
    Title Access and Privacy tracking information
    Legal Authority Consent if individuals, Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31,  s. 39(1)(b) and as necessary to the proper administration of access to information requests and privacy obligations
    Information Maintained Names, contact information, date of birth, descriptions of privacy breaches, access to information requests/letters, consent forms , access forms, access to health records requests
    Uses Resolve privacy breaches, respond to access requests
    Users Chief Privacy Officer, Freedom of Information Coordinator, Health Records department
    Individuals in Bank Some patients, substitute decision makers, individual requesters
    Retention & Disposal 7 years after superseded or, as applicable, after appeal rights expire
  • Human Resources Recruitment and Hiring
    Title Recruitment and Hiring
    Location Human Resources
    Legal Authority

    Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters

    Information Maintained Job applications, Resume, contact information, references, may include records related to application screening and acceptance/rejection of candidates
    Uses Hiring
    Users Human Resources staff
    Individuals in Bank Individuals who have applied for positions with Baycrest
    Retention & Disposal 3 years after creation date
  • Human Resources Information System
    Title Human Resources information system
    Location Human Resources, eHealth
    Legal Authority Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters
    Information Maintained Name, address, email address, telephone number, date of birth, education information, emergency contact information, names and dates of birth of beneficiaries and dependants, SIN, salary, disciplinary actions, pension data, Employee pay, performance and employment details
    Uses HR program administration
    Users Human Resources and Payroll staff
    Individuals in Bank Employees, paid students, post-doctoral and research fellows, retirees
    Retention & Disposal 3 years after creation date for general employment records
  • Human Resources Personnel Files
    Title Human Resources Personnel Files   
    Location Human Resources
    Legal Authority Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters
    Information Maintained Names, date of birth, contact information, education information, Opinions about performance, assessments, evaluations, time off requests, emergency contacts, job applications information, resumes, grievance information, criminal record checks, pension and benefit data, WSIB records, disciplinary actions, employment history, marital status, attendance and leave information, employment contracts, designated substance exposure records. .
    Uses   Human Resources program administration, departmental management
    Users Human Resources, applicable manager as appropriate
    Individuals in Bank  Employees, paid students, post-doctoral and research fellows, retirees
    Retention & Disposal 3 years after creation date for general employment records, 40 years for occupational health and safety, and workplace safety and insurance records
  • Legal Affairs Client/Family Records
    Title Client/Family Records
    Location Office of Director, Legal Affairs and law clerk
    Legal Authority As necessary to the proper administration of institution’s   legal affairs
    Information Maintained Client name, medical/psychiatric status, financial information, address, phone numbers, views, opinions, legal opinions, correspondence, marital or family status
    Uses To address legal issues facing Baycrest
    Users Director, Legal Affairs, law clerk, administrative assistant
    Individuals in Bank Patients, families, visitors
    Retention & Disposal 1 year after date of last use
  • Occupational Health & Safety Parklange System/Employee Health Files
    Title Parklange System/Employee Health Files
    Location Occupational Health & Safety, eHealth
    Legal Authority Consent of Individuals, Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), as necessary to the proper administration of the occupational  health and safety
    Information Maintained Employee health record
    Uses Documentation of employee health issues and incidents
    Users Occupational Health & Safety nurses and one administrator
    Individuals in Bank Employees
    Retention & Disposal  40 years
     
  • Ombudsperson’s Client Files
    Title Ombudsperson’s Client Files
    Location Office of Ombudsperson
    Legal Authority  Consent of individuals, Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), as necessary to the proper administration of ombudsperson functions, 
    Information Maintained Name, marital/family status, telephone number, address, email address, age, complaints/concerns related to Baycrest’s services/programs
    Uses Compliant follow up resolution
    Users Ombudsperson, administrative secretary
    Individuals in Bank Patients, residents, employees and family members
    Retention & Disposal 2 years from the date of file closure
    Or, if serious, until t finally resolved by settlement, judgment expiry of appeal period 
  • Organizational Effectiveness Tuition assistance applications
    Title Tuition assistance applications
    Location Organizational Effectiveness
    Legal Authority Consent of individuals and as necessary to the proper administration of  tuition assistance program 
    Information Maintained Employee name, home phone number, copy of void cheque, education information, course of study, final grade
    Uses Tuition assistance determination
    Users Organization Effectiveness and Finance staff
    Individuals in Bank Employees who have applied for tuition assistance
    Retention & Disposal One year after last use.
  • Strategic Advancement & Stakeholder Relations Media consent form
    Title Media consent form
    Location Public Affairs office
    Legal Authority  Consent of individuals
    Information Maintained Name, contact information
    Uses To obtain consent for media interviews, photos and videos
    Users Director, Public Relations
    Individuals in Bank Interviewees
    Retention & Disposal 1 year after date of last use
  • Support Services - List of Food & Nutrition Services Customers Information
    Title List of Food & Nutrition services customers information
    Location Food & Nutrition Services
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2)
    Information Maintained Name, patient or resident location, dietary requirements
    Uses Meal preparation
    Users Food & Nutrition staff
    Individuals in Bank Patients
    Retention & Disposal 7 years
  • Support Services Wandering Client Records
    Title Wandering client records
    Location Communications Desk
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) and as necessary to the proper administration of risk management and client safety
    Information Maintained Name, previous incidents, room number, patient description: photo, age, height, weight, eye colour, identifying marks
    Uses To monitor, safeguard and retrieve wandering clients
    Users Communications desk staff
    Individuals in Bank Wandering clients
    Retention & Disposal 2 years
  • Volunteer Services - Volunteer Information Files
    Title Volunteer Information Files
    Location Volunteer Services
    Legal Authority Consent of individuals, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75, and as necessary to the administration of  the volunteer program.
    Information Maintained Name, telephone number, address, date of birth, resumes, education and employment history, languages spoken, age, TB test results, hours worked, criminal record screening
    Uses Volunteer Services administration, assigning volunteers
    Users Volunteer Services staff
    Individuals in Bank Volunteers
    Retention & Disposal 1 year after date of last use
  • Research Participant Database
    Title Research Participant Database
    Location Web server
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s.36(1)(d)  and consent of individuals
    Information Maintained Subject ID, status notes, images/photos, group information, source, source type, participation date, availability (scheduling), methods of contact, participation frequency, date of birth, occupation, gender, handedness, languages spoken, music, education, weight, metal, condition, neurological information, disease rating, psychological information, medication, memory issues, research test data.
    Uses To compile research data about study participants
    Users All Research Ethics Board approved investigators and research testing personnel.
    Individuals in Bank Consented research participants (Baycrest staff, research staff, students, Baycrest patients, members of the community). Deidentified.
    Retention & Disposal 25 years
  • Research Contact Information Database
    Title Contact Information Database (Research)
    Location Encrypted excel file, on independent Research server
    Legal Authority  Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1)(d) and consent of individuals
    Information Maintained Research subject ID, name, license plate, address, telephone numbers, email address, address, Dx, MMSE score, MoCA score, BNA score
    Uses Contact information for all participants in the online research participant database
    Users Subject coordinator, research & subject assistant, research staff
    Individuals in Bank Consented research participants (Baycrest staff, research staff, students, Baycrest patients, members of the community)
    Retention & Disposal 25 years
  • Research - Stroke Patient Recovery Research Database (SPReD)
    Title Stroke Patient Recovery Research Database (SPReD)
    Location RRSI Sever Room
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s.36(1)(d) and consent of individuals
    Information Maintained Postal code, telephone numbers, Integrated Neuro-Cognitive Assessment System (INCAS) ID, health card number.
    Uses Data is used to uniquely assign internal IDs to subjects and to look for common subjects between multiple projects.
    Users Researchers of the Centre for Stroke Recovery
    Individuals in Bank Patients seen by neurologists using INCAS who have agreed to be contacted as research subjects.
    Retention & Disposal 25 years
  • Clinical and Residential - Ethics Referral Forms
    Title Ethics referral forms
    Location Clinical Ethics, administration
    Legal Authority  Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), and as necessary to the proper administration of clinical ethics program
    Information Maintained Names, contact information, physician, background, age, sex, admission number, room number, health card number, falls risk assessment score, height, weight, reason for referral
    Uses Resolve ethical issues at Baycrest
    Users Ethics office administrative staff
    Individuals in Bank Patients and family
    Retention & Disposal One year after last use
  • Infection Prevention & Control - Infection tracking files
    Title Infection tracking files
    Location Infection Prevention & Control
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2)
    Information Maintained Infection status of clients
    Uses Infection control surveillance and resolution
    Users Infection Prevention & Control staff
    Individuals in Bank Patients
    Retention & Disposal 7 years
  • Health Disciplines - Records of Inpatient Dispensing & Prescriptions
    Title Records of inpatient dispensing & prescriptions
    Location Pharmacy
    Legal Authority  Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2)
    Information Maintained Patient’s name, address, OHIP number, telephone numbers, account number, ordering physicians, prescription
    Uses Record of medication dispensed
    Users Pharmacy staff
    Individuals in Bank Hospital patients
    Retention & Disposal 2 years
  • Health Disciplines - Film Library
    Title Film Library
    Location Diagnostic Imaging
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2)
    Information Maintained Names, health card number, X-Rays
    Uses Retain and manage X-Rays
    Users Diagnostic Imaging staff
    Individuals in Bank Patients who had X-Rays
    Retention & Disposal 5 years after day on which the image is created.
  • Health Disciplines - Access Requests
    Title Access Requests
    Location Diagnostic Imaging administration
    Legal Authority Consent of individuals and as necessary to the proper administration of access to information requests 
    Information Maintained Access request for diagnostic images: name, health card number, date of birth, requested records
    Uses To respond to access to information requests
    Users Diagnostic imaging staff, health records staff
    Individuals in Bank Individuals who have made requests for information
    Retention & Disposal 7 years after superseded
  • Health Disciplines - Dosimeter Reports
    Title Dosimeter Reports
    Location Diagnostic Imaging
    Legal Authority Occupational Health and Safety Act, R.R.O. 1990, Reg. 861, s. 12(1)
    Information Maintained Amount of radiation exposure of staff
    Uses Ministry of Health and Long Term Care auditing
    Users Diagnostic Imaging staff, MoHLTC
    Individuals in Bank Diagnostic Imaging staff
    Retention & Disposal 3 years
  • Health Disciples - Physiotherapy Evaluation Database
    Title Physiotherapy evaluation database
    Location Physiotherapy administration offices
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2)
    Information Maintained Name, gender, health information related to patient’s condition, attendances, satisfaction ratings.
    Uses Program management and evaluation
    Users Physiotherapists
    Individuals in Bank Patients who participated in self-management programs
    Retention & Disposal 10 years after discharge or death
  • Health Disciples - Lab Test Results
    Title Lab test results
    Location Laboratory administration
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2)
    Information Maintained Names, address, telephone number, OHIP number,  test results
    Uses Provision of care
    Users Laboratory technicians
    Individuals in Bank Staff, patients
    Retention & Disposal 10 years after discharge or death
  • Quality, Safety & Best Practice - Event Tracking Reports
    Title Event tracking reports
    Location Quality Safety & Best Practice, various management offices
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) and as necessary to the proper administration of risk management program
    Information Maintained Name, date of birth, contact information, communication related to incident, details and description of incident,
    Uses Incident investigation and resolution
    Users Patient Safety Officer & Risk Manager; Director, Quality, Safety & Best Practice; appropriate leadership
    Individuals in Bank Employees, volunteers, students, clients, family members
    Retention & Disposal Until follow-up complete plus 2 years
  • Apotex Centre, Jewish Home for the Aged (long-term care home) - Resident Information
    Title Apotex Resident Information
    Location Apotex administration office
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), and as necessary to the proper administration of long-term care home
    Information Maintained Resident ID, name, family names, contact information, medical history, prescriptions.
    Uses Provision of care
    Users Apotex nursing staff, circle of care
    Individuals in Bank Apotex residents
    Retention & Disposal One year after last use
  • Terraces of Baycrest - Terraces Resident Information
    Title Terraces Resident Information
    Location Terraces health centre
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), consent of individuals, and as necessary to the proper administration of a retirement home.
    Information Maintained Name, resident photo directory, floor listings, list of admissions and discharges, care plans, medical charts, intake assessments, home safety assessments, billing information, name, medical history, family contact information, medical opinions, prescriptions, financial information
    Uses Provide care for and safeguard clients
    Users Terraces administrative staff
    Individuals in Bank Terraces residents
    Retention & Disposal 7 years from last date of residency
  • Terraces of Baycrest - Lifeline Monitoring Information
    Title Lifeline Monitoring Information
    Location Terraces administration office
    Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) and consent of individuals.
    Information Maintained Name, apartment number, telephone number, tracking information
    Uses To provide information to monitoring company
    Users Administration office staff members

    Individuals in Bank

    Terraces residents

    Retention & Disposal

    7 years from last day of person’s residency