Emergency Social Services Forms

Name

Purpose

Number

Referral Form

Referrals Unit Workers or Level One ESS responders use this form to refer evacuees to suppliers of food, clothing, lodging etc. The form instructs suppliers to invoice the provincial government.

EMBC2395

Referral Form Record

Documentation Unit Workers use this form to record when they issue a Referral Form to a Referrals Unit Worker or a Level One ESS responder.

EMBC2395A

Emergency Support Services Rates Sheet

ESS volunteers provide this sheet to evacuees along with the Referral Form. It gives the maximum amounts of money evacuees can receive to provide for their basic needs.

EMBC2395R

Supplier Consent

Resource Acquisition Workers use this form when they reach an agreement with a private provider of emergency services. It includes a rate sheet that describes the good and services that can be reimbursed and their maximum rates. The form is not a legal agreement.

EMBC2396

ESS File

(Registration and Services Record)

Registration Unit Workers in reception centres use this form to register the identity, location and needs of people affected by an emergency. The form is only mandatory if an evacuee wants to be referred to the services of a private provider.

EMBC2576

ESS Follow-up Card

Documentation Unit Workers use this card to indicate that an ESS File (above) needs to be followed-up.

EMBC2576A

ESS Out Card

Documentation Unit Workers in reception centres use this when a completed ESS File (above) is taken from the master file.

EMBC2576B

Change of Information Form

Registration Unit Workers in reception centres use this form to update information of people who have already registered.

EMBC2622

Health Canada Inquiry Card

Inquiry Unit Workers at reception centres complete this card when members of the public inquire about relatives living in the disaster area. If a match is made, the information is provided to the public by the reception centre or a central registry if applicable.

HC/SC 3090