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Application for Consideration of an Third Party Collaboration

Personal Support Worker

This form is to be completed by a Third Party Service Provider as application for consideration of the provision of a Personal Support Worker in-classroom student support within schools of the Kawartha Pine Ridge District School Board. This form is to be submitted to the Supplemental Student Services Committee in keeping with Administrative Regulation ES - 3.8.4 and in accordance with PPM 149.

Part A: Third Party Information

Name of service provider:

Mailing address:

Web address:

Phone number and Fax number

Agency provides service in:

Peterborough County

Municipality of Clarington

Northumberland County

Executive Director/Owner:

Lead contact name, email and phone number:

Validation of agency status

A copy of accreditation or licence attached

Part B: Nature of Request

Request for a Personal Support Worker(s) to be funded by the Third Party Service Provider:

for a Kawartha Pine Ridge District School Board Employee.

and external to Kawartha Pine Ridge District School Board staff.

Part C: Service Description

Goals and objectives:

Target individual(s):

Expected outcomes:

Service time lines:

Full school year support

Partial school day support

Part D: Staff Qualifications and Responsibilities (Complete if external to KPRDSB)

Please list relevant agency staff, and their qualifications.

Roles and responsibilities of the stated staff in service delivery:

Part E: Supervision Schedule (Complete if external to KPRDSB)

Please list the name(s) of their supervisor(s).

Roles and responsibilities of the stated staff in service delivery:

Part F: Accessibility in our Schools

Please provide a description of any accessibility needs the Personal Support Worker may have. For example, accommodations required for assistive devices, service animals, etc.

Part G: Statement of Finances

Third Party Service Providers requesting consideration for funding a Personal Support Worker through KPRDSB shall be responsible only for reimbursing the Board for the actual expenses incurred including salary and salary-related costs and related expenditures, including transportation and special services. The amount will be communicated to the Third Party Service Provider prior to the completion of the Collaboration Agreement.

Include details here:

Part H: Evaluation of Service

The KPRDSB and Third Party Personal Support Worker(s) must collaborate on the evaluation of services provided as a component of the yearly review. Please describe the proposed method of evaluation. ***Attach any relevant measurement tools.

Part I: Police Records Check

It is understood that

when a Collaboration Agreement is signed, Third Party staff who are working in schools/or directly with students, will be required to obtain and submit to the Board a current police records check (including a vulnerable sector screening, and a pardoned sexual offender database search) prior to providing any services or programs in schools. Any expenses incurred will be the responsibility of the Third Party Service Provider.

under the terms of the Collaboration Agreement, KPRDSB has sole and unfettered discretion to prohibit external Third Party staff members from entering the schools and to terminate the Collaboration Agreement if the external agency fails to obtain or renew criminal reference checks according to KPRDSB Policy.

Part J: Proof of Insurance

It is understood that:

once a Collaboration Agreement is signed, the Third Party Service Provider is required to provide proof that their staff is covered by insurance while working on KPRDSB property. External agencies must carry their own insurance which includes professional malpractice coverage (minimum $2,000,000) to insure against civil litigations alleging incompetence, professional errors, omissions or charges laid by professional colleges or parents/legal guardians. Such a policy shall contain a cross liability clause, an endorsement certifying that KPRDSB is included as an additionally named insured, and that the policy will be valid for the entire period of the collaboration agreement. Evidence of insurance coverage must be submitted to the KPRDSB prior to the commencement of any programs or services in schools.

Part K: Proof of Certificate of Clearance

It is understood that:

once a Collaboration Agreement is signed, the Third Party Service Provider will provide a Certificate of Clearance from the Workplace Safety and Insurance Board indicating the provider is in good standing. The Provider will be required to provide a Certificate of Clearance every 60 days, where applicable.

Part L: Application Submission Information

Submission date:

Name of Third Party Service provider staff who completed the application.

Please print & sign form and submit to address below (right-click on document and select print):

I certify that the information provided above is accurate and true to the best of my knowledge.

____________________________ __________________________

Signature Position

Chair of the Supplemental Student Services Committee
Kawartha Pine Ridge District School Board
1994 Fisher Drive, PO Box 7190
Peterborough, Ontario
K9J 7A1

For Information Contact:
Secretary - Attendance and Counselling,
Psychological Services and Speech-Language
Extension 2176
Telephone: (705) 742-9773
Toll Free: 1-877-741-4577
Fax: (705) 760-8665
Website: www.kprschools.ca

Part M: FOR OFFICE USE ONLY

Date received: __________________________________

KPRDSB Supplemental Student Services Committee review date: ___________________________

Application Review:

◊ Program is consistent with KPRDSB's stated mission, vision, and values.

◊ External Personal Support Worker Service does not duplicate services by KPRDSB staff.

◊ Requests is for funding of a KPRDSB staff.

◊ Supervisory relationships are satisfactory.

◊ Adherence to KPRDSB standards of consent, confidentiality, equity, and human rights.

◊ Measurement/evaluation tools meet Board standards.

Application: ◊ Approved ◊ Declined

Reason for Denial: ______________________________________________________