Personal Service Settings Special Event Form

Personal Service Settings Special Event Application Form

The personal information on this special event application form is collected under the authority of the Health Protection and Promotion Act and will be used for the administration of Public Health programs. Any questions about the collection of this information should be directed to the Manager of Environmental Health, KFL&A Public Health, 221 Portsmouth Avenue, Kingston, Ontario, K7M 1V5, 613-549-1232 or 1-800 -267-7875,ext. 1243.

Completed form to be submitted to KFL&A Public Health ten (10) business days before the event.

Event information

Event name

Date of event

Additional Dates (Recurring event or multiple day event)

Time of the event

Event address

Vendor information

Business name

Business address

Phone number (999-999-9999)

E-mail

Service provider information

Name

Address

Phone number (999-999-9999)

E-mail

Single-use equipment

Yes

No

Multi-use equipment

Yes

No

Other (specify)

Multi-use equipment must be:

covered with single-use, disposable covers as permitted, or
cleaned and disinfected or sterilized as appropriate at an approved premises, and used as single-use equipment during the event.

Multi-use equipment to be used at event

Cuticle pushers

Nail clippers

Scissors

Tattoo machine or frame

Tweezers

Trays

Other (specify)

Approved sharps container provided

Yes

No

Will you provide client record forms

Yes

No

If yes, please upload a copy of client record forms

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Will you provide aftercare instructions

Yes

No

If yes, please upload a copy of aftercare instructions

Browse…

Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Hand hygiene stations

At booth

Portable hand washing station

Hand hygiene station supplies

Liquid soap in dispenser

Paper towel in dispenser

Alcohol-based hand sanitizer

Other (specify)

Cleaning and disinfecting

Cleaning products to be used

Disinfectants to be used

Storage of dirty equipment after use (All dirty equipment must be stored in puncture proof containers with tight fitting lids and transported to an approved reprocessing location for cleaning, disinfection and sterilization.)

By checking this box, I acknowledge I have read, understand, and agree that the information provided in this form is correct.

Yes

I would like to receive e-mail communication from KFL&A Public Health.

Yes

No

Form Builder

Personal Service Settings Special Event Application Form

Event information

Vendor information

Service provider information

Multi-use equipment must be:

Cleaning and disinfecting