S-4.2, r. 21 - Regulation respecting the designation procedure for certain members of the board of directors of a public institution

À jour au 1^er septembre 2012

Ce document a valeur officielle.

chapter S-4.2, r. 21

Regulation respecting the designation procedure for certain members of the board of directors of a public institution

Act respecting health services and social services

(chapter S-4.2, s. 137).

DIVISION I GENERAL

§ 1 . — Scope

1. This regulation applies to the designation of members of the board of directors of public institutions pursuant to section 137 of the Act respecting health services and social services (chapter S-4.2).

M.O. 2006-015, s. 1.

§ 2 . — Date of designations

2. The designations under this Regulation shall be made on the date established by the minister in accordance with section 137 of the Act, which must be within 30 days prior to the date established for the public election under section 135 of the Act.

The designated persons shall take office on the 30th day after the completion of the cooptation provided for in section 138 of the Act.

M.O. 2006-015, s. 2.

§ 3 . — Designation officer

3. The president and executive director of the health and social services agency in question or the person he or she designates for this purpose shall appoint an officer in charge of the designation process not later than 45 days before the day on which the designations are to be made. If the appointed officer is unable to act, the president and executive director of the agency in question or the person designated shall appoint a new officer.

Unless otherwise indicated, the word “officer” used herein refers to the officer in charge of the designation process, selected as stipulated in this section.

The officer may not run as a candidate or countersign for a candidate, and is not entitled to vote in any designation process pursuant to this Regulation.

M.O. 2006-015, s. 3.

4. The officer is responsible for carrying out the designation process and ensuring compliance with the rules set out herein. His or her duties notably include the following, depending on the circumstances:

(1)  obtain the list of bodies or persons to be involved in the designation process from the executive director of the institution;

(2)  give notice of the designation process;

(3)  receive and accept or refuse nominations;

(4)  inform voters of the voting procedure if there are more candidates than positions to fill;

(5)  appoint all scrutineers necessary for assistance in the performance of his or her duties;

(6)  supervise the conduct of the designation process;

(7)  count the votes;

(8)  declare candidates designated in accordance with this Regulation;

(9)  report the results of the designation process to the agency and executive director of the institution.

M.O. 2006-015, s. 4.

§ 4 . — Executive director

5. The executive director of an institution shall provide the officer with the technical and administrative support required for the performance of his or her duties.

He or she shall keep the original documents received from the officer and completed in accordance with Schedules I to VI in sealed envelopes for a period of at least 180 days from the date on which the designations are made.

M.O. 2006-015, s. 5.

DIVISION II DESIGNATIONS BY USER COMMITTEES

§ 1 . — Initiation of the designation process

6. Not later than 40 days before the day on which the designations are to be made, the executive director must forward the officer contact information for the user committee of each institution affected by the designation.

M.O. 2006-015, s. 6.

7. Not later than 35 days before the date of the designations, the officer shall forward a notice to all users committees affected to invite members to take part in the designation of 2 people as members of the board of directors.

This notice must mention the restrictions set out in section 150 and the third paragraph of section 151 of the Act and indicate the provisions that must be followed in the designation process.

M.O. 2006-015, s. 7.

§ 2 . — Designation by a single users committee

8. The user committee resolution designating 2 people to the board of directors must be adopted at a meeting at which the majority of committee members are present.

The officer must receive a copy of this resolution not later than 5:00 p.m. on the day before the designations are to be made, accompanied by original nomination papers provided for in Schedule I, duly completed and signed by each candidate.

After ensuring that each candidate’s nomination paper has been duly completed and signed, the officer shall draw up the designation certificate provided for in Schedule II and forward copies of this certificate, all nomination papers, and the user committee resolution to the agency within 3 days. Within the same period, he or she shall send the original documents to the executive director of the institution.

The executive director shall post a copy of the designation certificate in a location accessible to the members of the user committee in each of the institution’s facilities.

M.O. 2006-015, s. 8.

9. If there is no candidate or valid candidate, the designation officer shall complete the declaration of designation not made provided in Schedule III and send a copy to the agency within 3 days. Within the same period, he or she shall send the executive director of the institution the original of the certificate in question, as well as any original invalid nomination papers and a copy of the user committee resolution.

M.O. 2006-015, s. 9.

§ 3 . — Designation by multiple user committees

10. If the designation process involves more than one user committee, each committee can adopt a resolution at a meeting at which the majority of its members are in attendance to nominate 2 persons as members of the board of directors.

The second paragraph of section 8 applies to each user committee.

M.O. 2006-015, s. 10.

11. On the date of the designations, after ensuring that each candidate’s nomination paper has been duly completed and signed, the officer shall draw up the list of candidates.

M.O. 2006-015, s. 11.

12. If there is no candidate or valid candidate, the provisions of section 9 apply.

If the number of candidates is less than or equal to 2, the officer shall declare the candidates designated.

If there are more than 2 candidates, the officer shall declare the 2 candidates who received the greatest number of nominations designated.

If candidates have received the same number of nominations and this would result in more than 2 candidates’ being designated, the officer shall immediately draw lots from among the candidates who obtained the same number of nominations.

The provisions of the third and fourth paragraphs of section 8 then apply, with the necessary modifications.

M.O. 2006-015, s. 12.

DIVISION III DESIGNATION BY THE PHYSICIANS OF THE REGIONAL DEPARTMENT OF GENERAL MEDICINE

§ 1 . — Initiation of the designation process

13. This section applies only to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 3 of section 129 of the Act.

M.O. 2006-015, s. 13.

14. Not later than 40 days before the designations, the executive director of any institution referred to in section 13, using the contact information provided by the agency, shall forward a list of the physicians of the regional department of general medicine to the officer. The list must include an address where each physician can be reached.

M.O. 2006-015, s. 14.

15. Not later than 35 days before the date of the designations, the officer shall send written notice of the designation process to all physicians on the list and post the notice in a location accessible to these physicians in each of the institution’s facilities. The posted notice must be accompanied by a list of names of all physicians involved in the designation process.

Any physician whose name does not appear on the posted list or who notices an error on the list may contact the officer for the appropriate correction.

The notice must mention the restrictions set out in section 150 of the Act, the provisions that apply under paragraph 3 of section 129 of the Act, the nomination period, and the terms that must be followed in the designation process.

M.O. 2006-015, s. 15.

§ 2 . — Nominations

16. Nominations are made by means of nomination papers drawn up in accordance with Schedule IV.

The original, duly completed nomination paper must be signed by the candidate, countersigned by 2 members of the designation college, and received by the officer not later than 25 days before the date of the designations.

To provide more information to the voters, candidates may also complete the information sheet provided for in Schedule V and forward it along with their nomination papers.

M.O. 2006-015, s. 16.

17. The officer shall accept or refuse the nomination paper not later than 2 days after receiving it and shall give written notice of acceptance or refusal to the person who filed the paper. The officer shall complete the corresponding section of the nomination paper.

The officer shall not divulge the name of any candidate to anyone whomsoever before the end of the nomination period.

M.O. 2006-015, s. 17.

18. If there is no candidate or valid candidate by the end of the nomination period, the officer shall complete the declaration of designation not made provided for in Schedule III and send a copy to the agency within 3 days. Within the same period, he or she shall send the executive director of the institution the original of the declaration in question, as well as any original invalid nomination papers and information sheets.

M.O. 2006-015, s. 18.

§ 3 . — Designation by acclamation

19. If the officer has received only one valid nomination by the end of the nomination period, he or she shall declare the candidate designated. The officer shall then complete the certificate of designation in accordance with Schedule II and send a copy thereof together with the nomination paper to the agency within 3 days. Within the same period, he or she shall send the original documents to the executive director of the institution.

Not later than 10 days before the date of the designations, the executive director shall post a notice indicating the name of the person designated and the fact that there will not be an election, in an area accessible to the members of the designation college in all of the institution’s facilities.

M.O. 2006-015, s. 19.

§ 4 . — Candidate list and election notice

20. If there is more than one valid nomination at the end of the nomination period, the officer shall draw up the list of candidates and send written notice to all physicians in the designation college not later than 20 days before the designations. The notice must indicate the date, time, and location of the vote count, and must also include the candidate list.

The officer shall also post the polling notice in all locations where the designation process notice was posted in accordance with section 15.

M.O. 2006-015, s. 20.

§ 5 . — Voting procedure

21. The polling notice that the officer forwards to all physicians in the designation college must be accompanied by the following documents:

(1)  the information sheet provided for in Schedule V and filled out by a candidate, as the case may be;

(2)  a ballot paper initialed by the officer;

(3)  a vote envelope with no markings identifying the physician, in which the ballot paper will be inserted;

(4)  a return envelope bearing the physician’s name and addressed to the officer.

M.O. 2006-015, s. 21.

22. Voters must use the ballot papers and envelopes received from the officer.

Voters shall insert their ballot papers in the vote envelopes provided, which they shall then insert in their return envelopes.

Ballot papers must be received at the office of the designation officer not later than 5:00 p.m. on the day before the designations are to be made.

M.O. 2006-015, s. 22.

§ 6 . — Counting of votes, designation proclamation, and publication of results

23. Accompanied by scrutineers, the officer shall count the votes at the time indicated on the polling notice.

Only return envelopes bearing voters’ names shall be considered and checked against the voters list.

M.O. 2006-015, s. 23.

24. First, the vote envelopes containing the ballot papers are removed from the envelopes bearing voters’ names.

If a return envelope does not contain a vote envelope, the situation is noted on the vote count report provided for in section 26.

If a return envelope contains 2 or more vote envelopes, the votes are not counted and the situation is noted on the vote count report provided for in section 26.

M.O. 2006-015, s. 24.

25. Once all return envelopes have been opened, the scrutineers shall then count the votes in the presence of the officer.

The vote count shall be public.

The officer shall cancel any ballot paper that

(1)  has not been provided by the officer;

(2)  does not bear the initials of the officer;

(3)  has not been marked;

(4)  has been marked in favor of more candidates than the required number;

(5)  has been marked in favor of a person who is not a candidate;

(6)  has been marked elsewhere than in the spaces provided for that purpose;

(7)  bears fanciful or injurious entries;

(8)  bears a mark by which the voter can be identified.

The officer shall cancel a ballot paper by writing “Void” on it and initialing the paper. The number of rejected ballot papers shall be noted on the vote count report provided for in section 26.

M.O. 2006-015, s. 25.

26. The officer shall declare the candidate who obtains the greatest number of votes designated.

In the event of a tie vote, the officer shall immediately draw lots from among the candidates to designate a candidate.

The officer shall then fill out the vote count report provided for in Schedule VI.

M.O. 2006-015, s. 26.

27. The officer shall complete the designation certificate provided for in Schedule II and send a copy thereof together with the designated candidate’s nomination papers to the agency within 3 days.

Within the same period, the officer shall send the executive director of the institution the originals of these same documents, the nomination papers of undesignated candidates, all information sheets completed by the candidates, ballot papers, and the vote count report.

The executive director shall post a copy of the designation certificate in a location accessible to the members of the designation college in each of the institution’s facilities.

M.O. 2006-015, s. 27.

DIVISION IV DESIGNATION BY AND FROM AMONG THE BOARD OF PHYSICIANS, DENTISTS, AND PHARMACISTS

§ 1 . — Initiation of the designation process

28. This section applies only to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 4 of section 129 or paragraph 3 of section 130, 131 or 133 of the Act.

M.O. 2006-015, s. 28.

29. Not later than 40 days before the designations, the executive director of any institution referred to in section 28 must forward the officer the list of members of the board of physicians, dentists, and pharmacists of the institution or institutions.

M.O. 2006-015, s. 29.

30. Not later than 35 days before the date of the designations, the officer shall post a notice of the designation process in a location accessible to the members referred to in this section in each of the institution’s facilities. This notice must be accompanied by the list provided for in section 29.

Any member whose name does not appear on the list or who notices an error on the list may contact the officer for the appropriate correction.

The notice must mention the restrictions set out in section 150 of the Act and indicate the nomination period and the terms that must be followed in the designation process.

M.O. 2006-015, s. 30.

§ 2 . — Nominations

31. Nominations are made by means of nomination papers drawn up in accordance with Schedule I.

The original, duly completed nomination paper must be signed by the candidate and received by the officer not later than 25 days before the date of the designations.

M.O. 2006-015, s. 31.

32. The provisions of section 18 apply if by the end of the nomination period no candidates have been nominated or no valid nominations have been received.

M.O. 2006-015, s. 32.

§ 3 . — Designation by acclamation

33. The provisions of section 19 apply, with the necessary modifications, if the officer receives only one valid nomination by the end of the nomination period.

M.O. 2006-015, s. 33.

§ 4 . — Candidate list and designation process

34. If there is more than one valid nomination at the end of the nomination period, the officer shall draw up the list of candidates and send it to the chair of the executive committee of the board of physicians, dentists, and pharmacists of the institution or institutions not later than 20 days before the designations.

The officer shall also post this list in all locations where the designation process notice was posted in accordance with section 30.

M.O. 2006-015, s. 34.

35. The executive committee of the board of physicians, dentists, and pharmacists must hold a meeting of the members of this board not later than the day before the designations are to be made in order to choose a candidate for designation to the board of directors of the institution or institutions.

However, the executive committee of the board of physicians, dentists, and pharmacists may, with the officer’s written approval, use a different means of consultation for board members to participate in the designation of a candidate as a member of the board of directors.

M.O. 2006-015, s. 35.

36. The executive director of the institution shall provide the executive committee of the board of physicians, dentists, and pharmacists with the technical and administrative support required to hold the meeting or implement the means of participation chosen under section 35.

M.O. 2006-015, s. 36.

37. The chair of the executive committee of the board of physicians, dentists, and pharmacists must forward to the officer a written summary of the conduct and final result of the procedure used pursuant to section 35, not later than date on which the designations are made.

M.O. 2006-015, s. 37.

38. The officer shall complete the designation certificate provided for in Schedule II and send a copy thereof together with the designated candidate’s nomination paper to the agency within 3 days.

Within the same period, the officer shall send the executive director of the institution the originals of these same documents, the nomination papers of undesignated candidates, and the summary report from the chair of the executive committee of the board of physicians, dentists, and pharmacists.

The executive director shall post a copy of the designation certificate in a location accessible to the members of the board of physicians, dentists, and pharmacists in each of the institution’s facilities.

M.O. 2006-015, s. 38.

DIVISION V DESIGNATION BY AND FROM AMONG THE INSTITUTION’S BOARD OF MIDWIVES

39. This section applies only to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 4 of section 129 of the Act.

M.O. 2006-015, s. 39.

40. The provisions of section IV apply, with the necessary modifications, to designations to the board of directors by and from among the members of the institution’s board of midwives.

M.O. 2006-015, s. 40.

DIVISION VI DESIGNATION BY AND FROM AMONG THE BOARD OF NURSES

41. This section applies only to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 5 of section 129 or paragraph 4 of section 130, 131 or 133 of the Act.

M.O. 2006-015, s. 41.

42. The provisions of section IV apply, with the necessary modifications, to designations to the board of directors by and from among the members of the board of nurses.

M.O. 2006-015, s. 42.

DIVISION VII DESIGNATION BY AND FROM AMONG THE MULTIDISCIPLINARY BOARD AND PERSONS CONSIDERED PART OF THE BOARD

43. This section applies to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 6 of section 129 or paragraph 5 of section 130, 131 or 133 of the Act, as well as the provisions of section 133.0.1 of the Act.

M.O. 2006-015, s. 43.

44. The provisions of section IV apply, with the necessary modifications, to the designation of one to 3 persons to the board of directors, depending on the number required under the Act, from among the members of the multidisciplinary board, including nursing assistants.

The notice required under section 30 must stipulate the provisions that apply under paragraph 5 of section 130 of the Act, as the case may be.

M.O. 2006-015, s. 44.

DIVISION VIII DESIGNATION BY AND FROM AMONG PERSONNEL NOT MEMBERS OF THE INSTITUTION’S BOARD OF PHYSICIANS, DENTISTS, AND PHARMACISTS; BOARD OF MIDWIVES; BOARD OF NURSES OR MULTIDISCIPLINARY BOARD

45. This section applies to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 7 of section 129 or paragraph 6 of section 130, 131 or 133 of the Act.

M.O. 2006-015, s. 45.

46. The provisions of section III apply, with the exception of section 13 and with the necessary modifications, to designations to the board of directors by and from among the personnel of an institution referred to in this section.

The list of persons concerned by this designation, which the executive director must send to the officer, shall be drawn up from the contact information in the institution’s personnel files.

M.O. 2006-015, s. 46.

DIVISION IX DESIGNATIONS BY FOUNDATION BOARDS OF DIRECTORS

47. This section applies to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 8 of section 129 or paragraph 7 of section 130, 131 or 133 of the Act.

M.O. 2006-015, s. 47.

48. Not later than 40 days before the date of the designations, the executive director must send the officer the name and address of all institution foundations as defined in section 132.2 of the Act, as well as the name of the chairs of foundation boards.

M.O. 2006-015, s. 48.

49. Not later than 35 days before the date of the designations, the officer shall send the board of directors of each foundation in question notice of their right to take part in the designation of one or 2 persons, depending on the number required under the Act, to the board of directors.

M.O. 2006-015, s. 49.

50. The provisions of the second paragraph of section 7 and sections 8 to 12 apply, with the necessary modifications, to the designations referred to in this section.

M.O. 2006-015, s. 50.

DIVISION X DESIGNATIONS BY MEMBERS OF A LEGAL ENTITY REFERRED TO IN SECTION 139 OF THE ACT

51. This section applies to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 8 of section 129 or paragraph 7 of section 130, 131 or 133 of the Act.

M.O. 2006-015, s. 51.

52. Not later than 40 days before the date on which the designations are to be made, the executive director of any institution referred to in section 51 shall forward to the officer the contact information of the board of governors or delegates. If such a board does not exist, the executive director shall forward the names and addresses of the members of the legal entity.

M.O. 2006-015, s. 52.

53. Any member whose name does not appear on the list provided for in section 52 or who notices an error on the list may contact the officer for the appropriate correction.

M.O. 2006-015, s. 53.

54. Not later than 35 days before the date of the designations, the officer shall forward a notice to the board of governors or delegates or to the persons indicated in section 52 to invite members to take part in the designation of one or 2 people to the board of directors, depending on the number required under the Act.

This notice must indicate the number of members to be designated, the restrictions set out in section 150 and the third paragraph of section 151 of the Act, and the provisions that must be followed in the designation process.

M.O. 2006-015, s. 54.

55. The officer must receive a copy of the resolution adopted by the board of governors or delegates or the members of the legal entity making the required designation not later than 5:00 p.m. on the day before the designations are to be made, along with each candidate’s duly completed and signed nomination paper provided for in Schedule I.

The provisions of the third and fourth paragraphs of section 8, those of section 9, and those of sections 11 and 12 if the designation process involves members of more than one legal entity then apply, with the necessary modifications.

M.O. 2006-015, s. 55.

DIVISION XI DESIGNATIONS BY INSTITUTION-AFFILIATED UNIVERSITIES AND BY AND FROM AMONG MEDICAL RESIDENTS

56. This section applies only to public institutions at which the makeup of the board of directors is subject to the provisions of paragraph 8 of section 133 or the second paragraph of section 130.1 of the Act.

M.O. 2006-015, s. 56.

57. Not later than 40 days before the date of the designations, the executive director must send the officer the name and address of the universities affiliated with the institution, as well as the name of the chairs of their boards of directors.

M.O. 2006-015, s. 57.

58. The provisions of section III apply, with the exception of section 13 and with the necessary modifications, to the designation of medical residents pursuant to paragraph 8 of section 133 of the Act.

The list of medical residents that the executive director must send to the officer in compliance with section 14 shall be drawn up from the contact information provided by the universities in question.

M.O. 2006-015, s. 58.

59. Not later than 35 days before the date of the designations, the officer shall send a notice to the chair of the board of directors of any university affiliated with an institution referred to in section 56 mentioning the university’s right, alone or with another university, to designate 1 to 4 people to the institution’s board of directors, depending on the number required under the Act.

This notice must mention the restrictions set out in section 150 and the third paragraph of section 151 of the Act, the provisions that apply under paragraph 8 of section 133 or the second paragraph of section 133.1 of the Act, as the case may be, and the provisions that must be followed in the designation process.

M.O. 2006-015, s. 59.

60. The officer must receive a copy of the resolution adopted by the university’s board of directors making the designations not later than the day before the designations are to be made. It must be accompanied by original nomination papers for each designation, as provided for in Schedule I, duly completed and signed by each candidate.

The provisions of section 9 apply, with the necessary modifications, if by the end of the nomination period no candidates have been nominated or valid nominations received.

M.O. 2006-015, s. 60.

61. The officer shall draw up the list of candidates nominated by the universities in question.

If there is only one valid nomination, the officer shall declare the candidate designated. He or she shall then complete the designation certificate provided for in Schedule II and send a copy thereof together with the candidate’s nomination paper and any resolution received pursuant to section 60 to the agency within 3 days.

Within the same period, he or she shall send the original documents to the executive director of the institution.

M.O. 2006-015, s. 61.

62. If more than one candidate has been nominated, the person nominated by the greatest number of universities shall be designated a member of the institution’s board of directors.

In the event of a tie vote, the officer shall immediately draw lots from among the candidates to designate a candidate.

M.O. 2006-015, s. 62.

63. The officer shall complete the designation certificate provided for in Schedule II and send a copy thereof together with the designated candidate’s nomination paper to the agency within 3 days.

Within the same period, the officer shall send the executive director of the institution the originals of these same documents, the nomination papers of undesignated candidates, and all resolutions received under section 60.

The executive director shall post a copy of the designation certificate in a location accessible to the public in each of the institution’s facilities.

M.O. 2006-015, s. 63.

DIVISION XII FINAL PROVISION

64. (Omitted).

M.O. 2006-015, s. 64.

SCHEDULE I

(s. 8)

DESIGNATION

Nomination Paper

Institution(s)			I.D. No.
			
			
			
Designation college 					
Section I - Nomination			
Candidate’s last and first name		Sex
M	F	Date of birth
	Y	M	D
Address		Occupation	
Municipality	Province	Postal Code		Employer
				
			
Area Code	
Home phone	Area Code	
Work phone
Ext.		
			
Section II - Candidate’s consent			
CONDITIONS REQUIRED TO BE A MEMBER
OF AN INSTITUTION’S BOARD OF DIRECTORS			
1.	Québec resident;			
2.	Age of majority (18 or over);			
3.	Not be under wardship or guardianship;			
4.	Not found guilty in the past five years of a crime punishable by three or more years of incarceration;			
5.	Not have been dismissed as the member of an institution’s, regional board’s, or health and social service agency’s board of directors in the past three years;			
6.	Not have been declared guilty in the past three years of an infraction of the Act respecting health and social services or the regulations;			
7.	Not work for any of the institutions indicated above or at a center run by such institutions, unless the designation under this form is made by one of the following colleges: the board of physicians, dentists and pharmacists; board of nurses; multidisciplinary board; board of midwives; or nonclinical staff.			
I hereby acknowledge that I have read this information and declare that I meet the above conditions for candidacy. I also authorize the disclosure of the information on this form to the health and social service agency and Ministère de la Santé et des Services sociaux (MSSS) if I am designated a member of the board of directors. Information disclosed to the agency and MSSS is governed by the Act respecting Access to documents held by public bodies and the Protection of personal information.			
In witness whereof, I have signed in 	 on 					
				
		Candidate’s signature	
			
			
			
			
Section III - Acceptance by designation officer			
NOMINATION ACCEPTED		NOMINATION REJECTED	
Reason(s) for rejection: 				
				
				
	
Designation officer’s signature				
Date	
Pursuant to sections 64 and 65 of the Act respecting Access to documents held by public bodies and the Protection of personal information			
1.	The information on this form is gathered for the institution concerned and, if the candidate is designated, for the health and social service agency and Ministère de la Santé et des Services sociaux.	2.		The information transmitted to the agency and MSSS is used to make up records for management and control purposes of the members of health and social service institution boards.	3.	The following persons will have access to this information:
	Employees of the institution in question, the agency, and MSSS in the performance of their duties;
	Any other user meeting the requirements of the abovementioned act.	4.	All information on the form is required.

M.O. 2006-015, Sch. I.

SCHEDULE II

(s. 8)

DESIGNATION

Designation Certificate

Designation college: _________________________________________________________________

Number of positions to be filled: __________

Executive director of: ________________________________________________________________

Name of institution(s)

I, the undersigned, the officer in charge of the designation process, declare that on _________________ the following candidate(s) was (were) designated to the position of member of the board of directors of the above-mentioned institution(s):

Name

(1) ______________________________________________________________________________

(2) ______________________________________________________________________________

(3) ______________________________________________________________________________

( ) The number of candidates was lower than or equal to the number of positions to be filled.

( ) The number of candidates was higher than the number of positions to be filled, and the designated candidate(s) received the greatest number of nominations or votes.

( ) Due to an equal number of nominations or a tie vote, the candidate(s) ______________________________ was (were) designated in a draw held on ____________________

Signed in ____________________, on ____________________

_____________________________

Signature

_____________________________

Name of designation officer

M.O. 2006-015, Sch. II.

SCHEDULE III

(s. 9)

DESIGNATION

Declaration of Designation Not Made

Designation college: __________________________________________________________________

Institution(s): ________________________________________________________________________

I, the undersigned, the officer in charge of the designation process, hereby declare that no designation was made for the above institution(s), for the following reason:

No nominations were received ( )

No valid nominations were received ( )

Signed in _____________________, on _____________________

______________________________

Signature

______________________________

Name of designation officer

M.O. 2006-015, Sch. III.

SCHEDULE IV

(s. 16)

DESIGNATION

Nomination Paper

Institution			I.D. No.
			
			
			
Designation college: 				
Section I - Nomination		Section II - Nominators	
Candidate’s last and first name		1- Nominator’s last and first name*	
Sex
M 		F	Date of birth
	Y	M	D	Address	
			
Address		Phone	
Municipality	Province	Postal code		Nominator’s signature
				
			
Area code	
Home phone	Area code	
Work phone	
Ext.	2- Nominator’s last and first name*	
			
Occupation		Address	
Employer		Phone	
* Nominator must be a member of the above designation college.		Nominator’s signature	
Section III - Candidate’s consent			
CONDITIONS REQUIRED TO BE A MEMBER
OF AN INSTITUTION’S BOARD OF DIRECTORS			
1.	Québec resident;			
2.	Age of majority (18 or over);			
3.	Not be under wardship or guardianship;			
4.	Not found guilty in the past five years of a crime punishable by three or more years of incarceration;			
5.	Not have been dismissed as the member of an institution’s, regional board’s, or health and social service agency’s board of directors in the past three years;			
6.	Not have been declared guilty in the past three years of an infraction of the Act respecting health services and social services or the regulations.			
I hereby acknowledge that I have read this information and declare that I meet the above conditions for candidacy. I also authorize the disclosure of the information on this form to the health and social service agency and Ministère de la Santé et des Services sociaux if I am designated a member of the board of directors. Information disclosed to the agency and MSSS is governed by the Act respecting Access to documents held by public bodies and the Protection of personal information.			
In witness whereof, I have signed in 	 on 					
				
		Candidate’s signature	
Section IV - Acceptance by designation officer			
Nomination accepted		Nomination rejected	
Reason(s) for rejection: 				
				
						
				
	
Designation officer’s signature				
Date	
Pursuant to sections 64 and 65 or the Act respecting Access to documents held by public bodies and the Protection of personal information			
1.	 The information on this form is gathered for the institution concerned and, if the candidate is designated, for the health and social service agency and ministère de la Santé et des Services sociaux.	2. 		The information transmitted to the agency and MSSS is used to make up records for management and control purposes of the members of health and social service institution boards.	3.	 The following persons will have access to this information:
	Employees of the institution in question, the agency, and MSSS in the performance of their duties;
	Any other user meeting the requirements of the abovementioned act.	4. All information on the form is required.

M.O. 2006-015, Sch. IV.

SCHEDULE V

(s. 16)

DESIGNATION

Candidate Information Sheet

PHOTO

Institution(s): ________________________________________________________________________

Candidate’s name: ____________________________________________________________________

Municipality of Municipality of

residence: ____________________ workplace: ____________________

Candidate profile (education, occupation, experience):

Reasons for candidacy:

Social, community, volunteer involvement, etc.:

Candidate’s consent: I authorize the disclosure of the information herein as part of the designation process in which I am a candidate.

____________________ _________________________

Date Candidate’s signature

____________________ _________________________

Date Designation officer’s signature

M.O. 2006-015, Sch. V.

SCHEDULE VI

(s. 24)

DESIGNATION

Vote Count Report

Designation college: __________________________________________________________________

Institution(s): ________________________________________________________________________

In accordance with the polling notice, the vote count took place on ___________________________, in ____________________

Envelopes with voter identified: __________

Envelopes containing no vote envelopes: __________

Envelopes containing more than one vote envelope: __________

Vote envelopes counted: __________

Uncounted vote envelopes: __________

(1) Vote Count Report

Candidates Number of votes

(1) ____________________ ____________________

(2) ____________________ ____________________

(3) ____________________ ____________________ Valid ballots __________

(4) ____________________ ____________________ Rejected ballots __________

(5) ____________________ ____________________ Total __________

(2) Draw results

The following candidates received the same number of votes:

______________________________

______________________________

______________________________

______________________________

A random draw was held on ____________________, in ____________________

The following candidate’s name was drawn:

______________________________

Signed in ____________________, on ____________________

______________________________

Signature

______________________________________

Name of designation officer

______________________________________

______________________________________

______________________________________

Name(s) of scrutineer(s)

M.O. 2006-015, Sch. VI.

REFERENCES

M.O. 2006-015, 2006 G.O. 2, 2845