Substitute Decision Maker
(Delegate/Statutory Decision Maker)
(Delegate or Statutory Decision Makers Pursuant to section 2(j) of the Personal Directive Act)
Part I - Identification
1. Give personal information
Name of Person: _____________________ Date of birth (dd/mm/yyyy) __________________HCN: _________________
2. Provide delegate information
The person has a Personal Directive:
Yes – Complete “Declaration of a Delegate/ Statutory Decision Maker”
No - Complete “Give information on Statutory Decision Makers”
Names delegate(s) in Personal Directive
Copy provided for file:
Yes
Role of delegate(s)
No
If No, describe who maintains copy of Personal Directive: ________________________________________________
3. Give information on Statutory Decision Makers
Person has not made a Personal Directive, does not have a guardian with authority to make such decisions, and lacks the ability to understand
information that is relevant to the making of a personal-care decision and the ability to appreciate the reasonably foreseeable consequences of a
decision or lack of a decision relating to health care, accepting an offer of placement in an continuing care home or regarding home care
service(s).
Decisions will be made on behalf of _____________________________ (person’s name) by the nearest relative who is;





who is of the age of majority (or is a minor spouse)
has capacity
has had contact with the person named above within the preceding 12 months
is willing to act and
comes first on the following list
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Substitute Decision Maker
(Delegate or Substitute Decision Makers Pursuant to section 2(j) of the Personal Directive Act)
Part I cont. – Identification of Substitute Decision Maker
Relationship
Name
If not, state why
Spouse
Child
Parent
Person standing in loco
parentis
Sibling
Grandparent
Grandchild
Aunt or uncle
Niece or nephew
Other relative
Public Trustee
4. Sign form
The information I have provided is true to the best of my knowledge. Information has been provided by:
Client/other: __________________________________ If Other, State Relationship________________________________________
Care Coordinator/Administrator: ____________________________Date: _____________________________
5. Next Steps
Administrator to complete “Declaration of Substitute Decision Maker (Delegate or Statutory Decision Maker) Form” with the person who has
been identified as the legally appropriate substitute decision maker.
Note: May want to review annually or when changes occure.
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Substitute Decision Maker
(Delegate or Substitute Decision Makers Pursuant to section 2(j) of the Personal Directive Act)
Part II – Substitute Decision Maker Declaration
1. Give personal information
Name of Person: _____________________ Date of birth (dd/mm/yyyy) __________________HCN: _________________
2. Give information on Substitute Decision Maker
Pursuant to the Personal Directives Act;
Has Named a Delegate(s) in Personal Directive (copy of document for file) OR
A Statutory Decision Maker has been identified using the “Identification of Substitute Decision Maker” Form and who is;
 the nearest relative
 who is of the age of majority (or is a minor spouse)
 has capacity
 has had contact with the person named above within the preceding 12 months
 is willing to act and
 comes first on the following list (Please Circle One):
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
Spouse
Child
Parent
Person standing in loco parentis
Sibling
Grandparent
Grandchildren
Aunt or Uncle
Niece or Nephew
Other Relative
Public Trustee
3. Substitute Decision Maker Declaration
Delegate Declaration
I _________________________________ (print name) have been appointed as the maker’s delegate and agree to
act as the substitute decision maker on behalf of the identified person. I am willing to assume responsibility for the
provision or refusal of consent for personal care decisions, including health care decisions, for the person. I have
read and understand all of the above. I acknowledge and agree that the statements contained in this form are true
to the best of my knowledge and I will advise the Continuing Care program should there be a change in any of the
facts or statements I have made.
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Substitute Decision Maker
(Delegate or Substitute Decision Makers Pursuant to section 2(j) of the Personal Directive Act)
Or
Statutory Decision Maker Declaration
I _________________________________ (print name of identified substitute decision maker) agree to act as the
substitute decision maker on behalf of the person and by authority of the above noted category.
I am willing to assume responsibility for the provision or refusal of consent for health care decisions, a decision to
accept an offer of placement in a continuing-care home and home-care services decisions for the person.
I am of the age of majority (or a minor spouse), have the capacity and willingness to act and have had personal
contact with this person over the preceding 12 months.
I know of no other person in a higher ranking category, as listed above, who is able and willing to make these
decisions for the person.
I have read and understand all of the above. I acknowledge and agree that the statements contained in this form
are true to the best of my knowledge and I will advise the Continuing Care Program should there be a change in
any of the facts or statements I have made.
4. Sign and date form
Signature of the Substitute Decision Maker: _________________ Date: _______________________
Mailing address: ________________________________Telephone ____________________________
Health Care Provider ____________________________ Date: _______________
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