Circle of Excellence - Application Form

Employer Info

Company

Company Address

Website

Company Phone

Sector (statcan category) View STATCAN Categories

Mission

Number of employees in Canada

Contact Info

First Name

Last Name

Title

Department

Phone

Email

Address

Criteria Adherence

• Eligibility: employees with 12 months of service or longer
• Salary support: 80% or more
• Duration: Minimum of 4 weeks
• No reduction in benefits (vacation, disability, etc.)

Do you meet Criteria Adherence:
 Yes    No

Details if necessary

Optional Support

Do you provide paid time off for completion of tests and medical appointments that are part of the living donation assessment process?
 Yes    No

Details if necessary

Do you provide additional support for living donors to defray costs of travel/lodging?
 Yes    No

Details if necessary

Do you have cap on financial support per living donor?
 Yes    No

Details if necessary

Do you have a cap on number of donors you will support annually?
 Yes    No

Details if necessary

Do you have cap on annual expenditures?
 Yes    No

Details if necessary

What changes, if any, did you make to your policies and practices in order to comply with Living Donor Circle of Excellence requirements?

How do employees find out about supports available?

Other comments/suggestions