Current Page 1 Page 2 Preview Personal information on this form is collected under the Freedom of Information and Protection of Privacy Act, section 31(1) for the purpose of monitoring and managing significant events. If you have questions about the form, call the Community Care Facilities and Nursing Home Consultant at 902-368-4953. Identification Complete this section with both facility name and name of the submitter. Business/Organization Name Contact First Name Contact Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone 1 For example 902-555-5555 Telephone 2 For example 902-555-5555 Fax Number For example 902-555-5555 Email Address Facility Name Type of Facility - Select -Community CareNursing Home