Application Form - Public Service Commission

This application will exclusively serve the purpose of acquiring Employee Assistance and Respectful Workplace Programs (EARWP) services and will be transmitted directly to the EARWP Division. Any information received will be safeguarded in keeping with the Personal Health Information Act and Access to Information and Protection of Privacy Act, 2015.

"*" indicates required fields

1. General

Employee Name*

First Middle Last

If services are required for a family member, the EARWP application is created using the Employee name in order for your family member to access coverage.

Date of Birth*

Gender

2. Home Address

Address*

Street Address City Province Postal Code

3. Department

Department/Agency*

If your department is not listed, please contact the EARWP division via telephone at: (888) 729-2290.

4. Communication

Phone

Home Email*

Please be advised that confirmation of this electronic application submission will be sent to the home email address provided on the form.

Work Email*

Preferred Method of Contact

5. Age

Your Age

6. Region

Your Region

7. Position Status

Position Status

Position Type

8. Years of Service

Years of Service

9. Learned about Service

Learned about us

10. Nature of Referral

Nature of Referral

11. Presenting Problem

Presenting Problem

12. Emergency Contact Info

Name (Their name)

First Last

Relationship to You

Phone (their phone)

13. Extra Info

Have you used EARWP services within the past 4 years?

Please review our Information and Service Guidelines.

Consent Box*

I have read the Information and Service Guidelines

By clicking submit you acknowledge that your application and the information it contains are accurate. Your application will be forwarded to the EARWP Division, and an automated confirmation email will be sent to the provided email address on this form.

The personal information collected in this form will be used for the purpose of accessing and providing EARWP services. The information is collected under the authority of section 61(c) of the Access to Information and Protection of Privacy Act, 2015 and section 29 of the Personal Health Information Act. If you have any questions about the collection, use or disclosure of your personal information, please contact the Employee Assistance or Respectful Workplace coordinator at 709-729-2290.