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Temporary Foreign Worker Program

Live-in Caregiver Bedroom Description

This form must be completed and signed by both employers, when applicable, if the live-in caregiver will work in one location only. However, one form must be completed for each residence in which the live-in caregiver will reside (e.g. in case of divorced or separated parents, or if the employer(s) resides in multiple locations such as a cottage).

1. Employer's address of residence where the live-in caregiver will reside

Number / Street / PO Box # ____________________________________  

City ________________________________  

Province / Territory ____________________  

Postal Code __________________________  

Telephone number with area code ____________________________________  

2. Will the live-in caregiver have his/her own bedroom?

Yes __     No __

3. Is the live-in caregiver's bedroom located inside the premises where care will be given?

Yes __     No __

4. Does the live-in caregiver’s bedroom have a door with a lock, whose key will be provided to him/her, and is there a safety bolt?

Yes __     No __

5. Does the live-in caregiver's bedroom have a secure exterior window that closes and locks from within?

Yes __     No __

6. What are the dimensions of the bedroom being assigned to the live-in caregiver? (e.g. 9 m² or 2.7 m x 3.40 m)

_______________________________________

7. Does the bedroom provided to the caregiver include:

Finished walls
Yes __     No __

Finished floors
Yes __     No __

Finished ceilings
Yes __     No __

Heating
Yes __     No __

Lighting
Yes __     No __

Closet
Yes __     No __

Bed with mattress
Yes __     No __

Bedding : (sheets, pillows, blankets)
Yes __     No __

8. Provide additional details about furniture and/or services (e.g. telephone, television, cable or satellite, Internet, etc.), if applicable, for the live-in caregiver's bedroom:

_______________________________________

 

Name of employer #1 (please print) ____________________________________  

Signature of employer #1 ____________________________________  

Date (DD/MM/YYYY) _________________  

 

Name of employer #2 (if applicable, please print) ____________________________________  

Signature of employer #2 (if applicable) ____________________________________  

Date (DD/MM/YYYY) _________________  

 

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Date Modified:

2012-02-03