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AR 26/98 PERSONAL DIRECTIVES (MINISTERIAL) REGULATION

(Consolidated up to 27/2016)

ALBERTA REGULATION 26/98

Personal Directives Act

PERSONAL DIRECTIVES (MINISTERIAL) REGULATION

Table of Contents


                2      Designation by name of office or position

                3      Persons to contact

                4      Service of originating notice

                5      Forms

                6      Expiry

                7      Repeal

Schedules

1   Repealed AR 98/2008 s3.

Designation by name of office or position

2(1)  For the purposes of section 7(3) of the Act, persons who are service providers to a maker may not be designated by the maker as agents by office or position.

(2)  Persons referred to in subsection (1) may only be designated as agents by their name.

Persons to contact

3(1)  For the purposes of sections 19(2) and 24(2) of the Act, if no nearest relative can be contacted, then every reasonable effort must be made to contact the maker’s legal representative.

(2)  If none of the maker’s legal representatives can be contacted, the Public Guardian must be contacted.

Service of originating notice

4   For the purposes of section 26(1) of the Act, the application must be served on the following persons:

                               (a)    the maker’s legal representatives;

                              (b)    the maker’s nearest relative.

AR 26/98 s4;164/2010

Forms

5(1)  The form of a personal directive for the purposes of section 6.1 of the Act is set out in Schedule 1.

(2)  The form of a declaration for the purposes of section 9(2)(a) of the Act is set out in Schedule 2.

(3)  The form of a declaration for the purposes of section 9(2)(b) of the Act is set out in Schedule 3.

(4)  The form of a determination for the purposes of section 10.1(1) of the Act is set out in Schedule 4.

(5)  The form of a determination for the purposes of section 10.1(2) of the Act is set out in Schedule 5.

(6)  The form of a determination for the purposes of section 10.1(5) of the Act is set out in Schedule 6.

(7)  The form of a complaint for the purposes of section 24.2 of the Act is set out in Schedule 7.

AR 26/98 s5;98/2008

Expiry

6   For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on March 31, 2018.

AR 26/98 s6;106/2002;59/2003;40/2013;181/2013;27/2016

Repeal

7   The Personal Directives Regulation (AR 225/97) is repealed.


Schedule 1

Personal Directive
(Section 6.1)

I,    (name of maker)   , make this Personal Directive.

This Personal Directive takes effect with respect to personal matters that relate to me when it is determined, in accordance with the Personal Directives Act, that I do not have capacity to make personal decisions with respect to those matters.

I have placed my initials next to the provisions in this document that form part of my Personal Directive.

1.  Revocation of previous personal directive

Initials              I revoke all previous personal directives made by me.

2.  Designation of agent

Initials              I designate    (name of agent or agents)    as my agent(s).

OR

Initials              I designate the Public Guardian as my agent.

I have consulted with the Public Guardian and the Public Guardian is satisfied that no other person is able and willing to act as my agent. The Public Guardian has agreed to be my agent.

OR

Initials              I do not wish to designate an agent, but provide the following information and instructions to be followed by a service provider who intends to provide personal services to me:

                                                                                                               

3.  Areas of authority

Initials              I give my agent(s) the authority to make personal decisions on my behalf for all the personal matters, of a non‑financial nature, that relate to me.

OR

Initials             I give the following agent(s) the authority to make personal decisions on my behalf for the following personal matters, of a non‑financial nature, that relate to me:

                                       Initials              health care             (name of agent(s))    ;
Initials              accommodation     (name of agent(s))    ;
Initials              with whom I may live and associate
      (name of agent(s))   ;
Initials              participation in social activities
      (name of agent(s))   ;
Initials              participation in educational activities
      (name of agent(s))   ;
Initials              participation in employment activities
      (name of agent(s))   ;
Initials              legal matters     (name of agent(s))         ;

                                       Initials              other personal matters as follows       (name of agent(s))   :
                                                                                                

4.  Designation of agent for temporary care and education of minor child(ren) (Optional)

Initials              I designate    (name of agent)    as an agent who has the authority to take over the care and education of my minor child(ren) until one of the events described in section 7(1)(e) of the Act happens.

5.  Specific instructions (Optional)

Initials              I instruct my agent(s) to carry out the following specific instructions when making decisions about my personal matters:                               

 

Initials______ If I have not designated an agent, or if my agent(s) are unable or unwilling to make a personal decision or cannot be contacted after every reasonable effort has been made, I instruct a service provider who intends to provide personal services to me to follow the following instructions that are relevant to the decision to be made:  

6.  Other information (Optional)

Initials              I provide the following information to help my agent(s) understand my wishes, beliefs and values when making decisions about my personal matters:

7.  Who determines my capacity (Optional)

Initials              I designate    (name of individual(s))   , to determine my capacity under section 9 of the Personal Directives Act.

8.  Notification (Optional)

Initials              If a determination is made under the Personal Directives Act that I lack capacity to make personal decisions, I instruct the person making the determination to provide a copy of the declaration to me, the agent(s) I have designated in this Personal Directive, if any, and the following people:                                   

9.  Signatures

Signed by me in the presence of my witness at    (location)   , in the Province of Alberta, this    (day)    of    (month)   ,    (year)   .

 

  (signature of maker)       (signature of witness in the presence of maker)   
                                                     (printed name of witness)                   
                                                         (address of witness)                        

Note:  Witness should also initial provisions initialled by maker.

Note:  The following persons may not witness the signing of a personal directive:

● a person designated in the directive as an agent
● the spouse or adult interdependent partner of a person designated in the directive as an agent
● the spouse or adult interdependent partner of the maker
● a person who signs the directive on behalf of the maker
● the spouse or adult interdependent partner of a person who signs the directive on behalf of the maker

10.  Acknowledgement (Optional)

I (We) acknowledge that I(we) have received a copy of this personal directive.

 

Name of Agent

Signature of Agent

Location Where Signed

Date of Signing

Telephone Numbers of Agent

Mailing Address of Agent

E-mail Address of Agent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AR 98/2008 s5

Schedule 2

Declaration of Incapacity to Make Decisions
about a Personal Matter (Section 9(2)(a))

(To be used when a person designated in the personal directive to determine capacity consults with a physician or psychologist.)

Part 1

(To be completed by the person designated in the personal directive to determine capacity after consultation with a physician or psychologist.)

“capacity” means the ability to understand the information that is relevant to the making of a personal decision and the ability to appreciate the reasonably foreseeable consequences of the decision (s1(b) of the Personal Directives Act).

I,    (name)   , am designated in the personal directive made by the maker,    (name of maker)   , as the person who is to determine his/her capacity.

Before conducting an assessment of the capacity of the maker, I met with the maker and explained the purpose and nature of the assessment, the maker’s right to refuse to be assessed and the significance and effect of a finding that the maker lacks capacity to make personal decisions.

The reason(s) I assessed the maker’s capacity are as follows:
                                                                                                               

I identified that an assessment of the maker’s capacity to make personal decisions was warranted with respect to the following personal matters:          

After consulting with    (name of Alberta physician or psychologist)    and interviewing the maker, I have determined and declare that    (name of maker)    lacks the capacity to make decisions about the following personal matter(s) of a non‑financial nature (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

The reasons for my determination are as follows:

1.   The level of consciousness of the maker at the time of my determination was (check one):
     
  alert
     
  fluctuating
     
  non‑responsive

2.   It is my understanding that all temporary medical conditions that may affect the maker’s capacity have been ruled out:
     
  YES

3.   In my opinion, the maker:

                                 ●    Is unable to understand the information that is needed to make a decision about the above‑specified personal matter(s) and is unable to understand the options presented.   Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to retain the information that is relevant to making a decision about the above‑specified personal matter(s).
  
Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to identify and appreciate the consequences of making or not making a decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to communicate his/her decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

I recommend that this declaration be reviewed on          (date)       . (Optional)   

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of person                      Printed name of person               
completing Part 1                          completing Part 1                        

Part 2

(To be completed by the physician or psychologist consulted by the person who completed Part 1.)

I,     (name)   , am a member in good standing of the    (College of Physicians and Surgeons of the Province of Alberta/College of Alberta Psychologists)   .

Before conducting an assessment of the capacity of the maker,    (name of maker)   , I met with the maker and explained the purpose and nature of the assessment, the maker’s right to refuse to be assessed and the significance and effect of a finding that the maker lacks capacity to make personal decisions.

I have interviewed the maker and consulted with    (name of person who completed Part 1)   .

The reason(s) I assessed the maker’s capacity are as follows:
                                                                                                               

I am of the opinion that    (name of maker)    lacks the capacity to make decisions about the following personal matter(s) of a non‑financial nature (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

The reasons for my determination are as follows:

1.   The level of consciousness of the maker at the time of my determination was (check one):
     
  alert
     
  fluctuating
     
  non‑responsive

2.   Based on a medical evaluation by    (name of physician)    on    (day/month/year)   , all temporary medical conditions that may affect the capacity of the maker have been ruled out:
     
  YES

3.   In my opinion, the maker:

                                 ●    Is unable to understand the information that is needed to make a decision about the above‑specified personal matter(s) and is unable to understand the options presented.   Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to retain the information that is relevant to making a decision about the above‑specified personal matter(s).
  
Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to identify and appreciate the consequences of making or not making a decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to communicate his/her decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

4.   I have attached a more detailed capacity assessment or report.  (Optional)    Yes     No

I recommend that this declaration be reviewed on          (date)       .  (Optional)   

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of physician/                  Printed name of physician/      
psychologist completing Part 2   psychologist completing Part 2

AR 26/98 Sched.;59/2003;98/2008

Schedule 3

Declaration of Incapacity to Make Decisions
about a Personal Matter (Section 9(2)(b))

Part 1

(To be completed by a service provider who is a physician or psychologist.)

“capacity” means the ability to understand the information that is relevant to the making of a personal decision and the ability to appreciate the reasonably foreseeable consequences of the decision (s1(b) of the Personal Directives Act).

I,    (name)   , am a member in good standing of the    (College of Physicians and Surgeons of the Province of Alberta/College of Alberta Psychologists)   .

Before conducting an assessment of the capacity of the maker,    (name of maker)   , I met with the maker and explained the purpose and nature of the assessment, the maker’s right to refuse to be assessed and the significance and effect of a finding that the maker lacks capacity to make personal decisions.

The reason(s) I assessed the maker’s capacity are as follows:
                                                                                                               

I identified that an assessment of the maker’s ability to make personal decisions was warranted with respect to the following personal matters:          

I have interviewed the maker and have determined that the maker lacks the capacity to make a decision about the following personal matter(s) of a non‑financial nature (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

The reasons for my determination are as follows:

1.   The level of consciousness of the maker at the time of my determination was (check one):
     
  alert
     
  fluctuating
     
  non‑responsive

2.   Based on a medical evaluation made by    (name of physician)    on    (day/month/year)   , all temporary medical conditions that may affect the capacity of the maker have been ruled out:       YES

3.   In my opinion, the maker:

                                 ●    Is unable to understand the information that is needed to make a decision about the above‑specified personal matter(s) and is unable to understand the options presented.   Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to retain the information that is relevant to making a decision about the above‑specified personal matter(s).
  
Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to identify and appreciate the consequences of making or not making a decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to communicate his/her decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

4.   I have attached a more detailed capacity assessment or report.  (Optional)    Yes     No

I recommend that this declaration be reviewed on          (date)       .  (Optional)   

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of physician/                  Printed name of physician/      
psychologist completing Part 1   psychologist completing Part 1

Part 2

(To be completed by a service provider.)

I,    (name)   , am    (title/position of service provider)   .

Before conducting an assessment of the capacity of the maker,    (name of maker)   , I met with the maker and explained the purpose and nature of the assessment, the maker’s right to refuse to be assessed and the significance and effect of a finding that the maker lacks capacity to make personal decisions.

The reason(s) I assessed the maker’s capacity are as follows:
                                                                                                               

I identified that an assessment of the maker’s ability to make personal decisions was warranted with respect to the following personal matters:          

I have interviewed the maker and have determined that the maker lacks the capacity to make a decision about the following personal matter(s) of a non‑financial nature (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

The reasons for my determination are as follows:

1.   The level of consciousness of the maker at the time of my determination was (check one):
     
  alert
     
  fluctuating
     
  non‑responsive

2.   It is my understanding that all temporary medical conditions that may affect the maker’s capacity have been ruled out:
     
  YES

3.   In my opinion, the maker:

                                 ●    Is unable to understand the information that is needed to make a decision about the above‑specified personal matter(s) and is unable to understand the options presented.   Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to retain the information that is relevant to making a decision about the above‑specified personal matter(s).
  
Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to identify and appreciate the consequences of making or not making a decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is unable to communicate his/her decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

4.   I have attached a more detailed capacity assessment or report.  (Optional)                                                                                  Yes       No

I recommend that this declaration be reviewed on          (date)       .  (Optional)   

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of service                         Printed name of service          
provider completing Part 2             provider completing Part 2     

AR 26/98 Sched.;59/2003;98/2008

Schedule 4

Determination of Regained
Capacity (Section 10.1(1))

(To be used after a personal directive is in effect when an agent of the maker notices a significant change in the maker’s capacity and a service provider who provides health care services agrees that the maker has regained the capacity to make decisions about personal matters.)

Part 1

“capacity” means the ability to understand the information that is relevant to the making of a personal decision and the ability to appreciate the reasonably foreseeable consequences of the decision (s1(b) of the Personal Directives Act).

“significant change” means an observable and sustained improvement that does not appear to be temporary (s1(o) of the Personal Directives Act).

The maker,    (name of maker)   , has a personal directive that is in effect with respect to the following personal matters:

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

I,    (name of agent)   , am designated in the maker’s personal directive as an agent with authority to make personal decisions for the following personal matters:

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

I spoke with the maker,    (name of maker)   , about whether he/she has regained capacity to make personal decisions. (Required)

I spoke with    (name of service provider)   , a service provider who has recently provided a health care service to the maker, about whether the maker has regained capacity to make personal decisions. (Required)

I spoke with    (name of agent(s))   , other agents named in the personal directive, about whether the maker has regained capacity to make personal decisions.  (Optional)

I have reviewed health or other records about the maker that are relevant to my assessment of the maker’s capacity, and have discussed the records with    (name of physician or health care practitioner)   , the maker’s physician or other health care practitioner. (Optional)

I have considered recent statements or recommendations made by    (names of health care practitioners)   , health care practitioners who were consulted about the maker’s capacity. (Optional)

In assessing whether the maker has regained capacity:

1.     I have observed a significant change in the maker’s capacity, OR

  I am satisfied that    (name of service provider)   , a service provider who provides health care services to the maker, has observed a significant change in the maker’s capacity. 

(One of the above is required)

2.     I have considered statements or other evidence provided by    (name)   , a service provider, agent or other person, that corroborate that there has been a change in the maker’s capacity to make personal decisions. (Required)

Details respecting the statements or other evidence I considered are as follows:
                                                                                                               

3.     I considered the following period of time over which the change in the maker’s capacity was observed by the service provider, agents or other person: _________to _________. (Required)

I have determined that the maker has regained the capacity to make decisions about the following personal matter(s) (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

In addition to my opinions expressed above, I wish to add the following comments in support of my determination (Optional):
                                                                                                               

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of agent                                  Printed name of agent        

Part 2

I,    (name of service provider)   , am a service provider who provides health care services.

I have consulted with    (name of agent who completed Part 1)   , an agent of the maker, about whether the maker has regained capacity to make personal decisions. (Required)

I spoke with the maker,    (name of maker)   , about whether he/she has regained capacity to make personal decisions. (Required)

I spoke with    (name of service provider)   , a service provider who has recently provided a health care service to the maker, about whether the maker has regained capacity to make personal decisions. (Required)

I spoke with    (name of agent(s))   , other agents named in the personal directive, about whether the maker has regained capacity to make personal decisions.  (Optional)

I have reviewed health or other records about the maker that are relevant to my assessment of the maker’s capacity, and have discussed the records with    (name of physician or health care practitioner)   , the maker’s physician or other health care practitioner. (Optional)

I have considered recent statements or recommendations made by    (names of health care practitioners)   , health care practitioners who were consulted about the maker’s capacity. (Optional)

In assessing whether the maker has regained capacity:

1.   I am satisfied that

      (name of agent)   an agent of the maker, or 

      (name of service provider)   a service provider who provides health care services to the maker,

has directly observed a significant change in the maker’s capacity. 

(One of the above is required)

2.     I have considered statements or other evidence provided by    (name)   , a service provider, agent or other person, that corroborate that there has been a change in the maker’s capacity to make personal decisions. (Required)

Details respecting the statements or other evidence I considered are as follows:
                                                                                                               

3.     I considered the following period of time over which the change in the maker’s capacity was observed by the service provider, agents or other person: _________to _________. (Required)

I have determined that the maker has regained the capacity to make decisions about the following personal matter(s) (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

In addition to my opinions expressed above, I wish to add the following comments in support of my determination (Optional):
                                                                                                               

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of                                        Printed name of                       
service provider                               service provider                       

AR 98/2008 s5

Schedule 5

Determination of Regained
Capacity (Section 10.1(2))

(To be used after a personal directive is in effect when a service provider who provides or intends to provide health care services to the maker notices a significant change in the maker’s capacity.)

Part 1

“capacity” means the ability to understand the information that is relevant to the making of a personal decision and the ability to appreciate the reasonably foreseeable consequences of the decision (s1(b) of the Personal Directives Act).

“significant change” means an observable and sustained improvement that does not appear to be temporary (s1(o) of the Personal Directives Act).

The maker,   (name of maker)   , has a personal directive that is in effect with respect to the following personal matters:

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

I,    (name of service provider)   , am a service provider who provides or intends to provide health care services to the maker.

I spoke with the maker,     (name of maker)   , about whether he/she has regained capacity to make personal decisions. (Required)

I spoke with    (name of service provider)   , a service provider who has recently provided a health care service to the maker, about whether the maker has regained capacity to make personal decisions. (Required)

I spoke with    (name of agent(s))   , agent(s) named in the personal directive, about whether the maker has regained capacity to make personal decisions.  (Optional)

I have reviewed health or other records about the maker that are relevant to my assessment of the maker’s capacity, and have discussed the records with    (name of physician or health care practitioner)   , the maker’s physician or other health care practitioner. (Optional)

I have considered recent statements or recommendations made by    (names of health care practitioners)   , health care practitioners who were consulted about the maker’s capacity. (Optional)

In assessing whether the maker has regained capacity:

1.   I am satisfied that

      (name of agent)   , an agent of the maker, or 

      (name of service provider)   , a service provider who provides health care services to the maker,

has directly observed a significant change in the maker’s capacity. 

(One of the above is required)

2.     I have considered statements or other evidence provided by    (name)   , a service provider, agent or other person, that corroborate that there has been a change in the maker’s capacity to make personal decisions. (Required)

Details respecting the statements or other evidence I considered are as follows:
                                                                                                               

3.     I considered the following period of time over which the change in the maker’s capacity was observed by the service provider, agents or other person: _________to _________. (Required)

I have determined that the maker has regained the capacity to make decisions about the following personal matter(s) (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

In addition to my opinions expressed above, I wish to add the following comments in support of my determination (Optional):
                                                                                                               

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of                                        Printed name of                       
service provider                               service provider                       

Part 2

(To be used if an agent is designated in the personal directive with authority to make personal decisions in the personal matter noted in Part 1 above.)

I,    (name of agent)   , am designated in the maker’s personal directive as an agent with authority to make personal decisions for the following personal matters:

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

I have consulted with    (name of service provider who completed Part 1)   , a service provider who provides or intends to provide health care services to the maker, about whether the maker has regained capacity to make personal decisions. (Required)

I spoke with the maker,    (name of maker)   , about whether he/she has regained capacity to make personal decisions. (Required)

I spoke with    (name of service provider)   , a service provider who has recently provided a health care service to the maker, about whether the maker has regained capacity to make personal decisions. (Required)

I spoke with    (name of agent(s))   , other agents named in the personal directive, about whether the maker has regained capacity to make personal decisions.  (Optional)

I have reviewed health or other records about the maker that are relevant to my assessment of the maker’s capacity, and have discussed the records with    (name of physician or health care practitioner)   , the maker’s physician or other health care practitioner. (Optional)

I have considered recent statements or recommendations made by    (names of health care practitioners)   , health care practitioners who were consulted about the maker’s capacity. (Optional)

In assessing whether the maker has regained capacity:

1.   I am satisfied that

      (name of agent)   , an agent of the maker, or 

      (name of service provider)   , a service provider who provides health care services to the maker,

has directly observed a significant change in the maker’s capacity. 

(One of the above is required)

2.     I have considered statements or other evidence provided by    (name)   , a service provider, agent or other person, that corroborate that there has been a change in the maker’s capacity to make personal decisions. (Required)

Details respecting the statements or other evidence I considered are as follows:
                                                                                                               

3.     I considered the following period of time over which the change in the maker’s capacity was observed by the service provider, agents or other person: _________to _________. (Required)

I have determined that the maker has regained the capacity to make decisions about the following personal matter(s) (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

In addition to my opinions expressed above, I wish to add the following comments in support of my determination (Optional):
                                                                                                               

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of agent                            Printed name of agent              

AR 98/2008 s5

Schedule 6

Determination of Regained
Capacity (Section 10.1(5))

(To be completed by 2 service providers, one of whom is a physician or psychologist, after a personal directive is in effect when the agent and a service provider who provides health care services to the maker disagree that the maker has regained the capacity to make decisions about personal matters.)

Part 1

“capacity” means the ability to understand the information that is relevant to the making of a personal decision and the ability to appreciate the reasonably foreseeable consequences of the decision (s1(b) of the Personal Directives Act).

“significant change” means an observable and sustained improvement that does not appear to be temporary (s1(o) of the Personal Directives Act).

I,    (name of consulted physician/psychologist)   , am a member in good standing of the    (College of Physicians and Surgeons of the Province of Alberta/College of Alberta Psychologists)   .

I was asked by    (name of agent or service provider)    to assess the capacity of the maker,   (name of maker)   , because the maker’s agent and a service provider who provides health care services to the maker have assessed the maker’s capacity and disagree about whether the maker has regained the capacity to make decisions about personal matters.

I identified that an assessment of the maker’s ability to make personal decisions was warranted with respect to the following personal matters:          

Before conducting an assessment of the maker’s capacity, I determined that it was in the best interest of the maker to conduct the assessment, and met with the maker and explained to the maker the purpose and nature of the assessment.

I have interviewed the maker and determined that he/she has regained the capacity to make decisions about the following personal matter(s) of a non‑financial nature (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

The reasons for my determination are as follows:

1.   The level of consciousness of the maker at the time of my determination was (check one):
     
  alert
     
  fluctuating
     
  non‑responsive

2.   I have identified and ruled out any temporary medical conditions that may affect the maker’s capacity to make personal decisions:       Yes

3.   In my opinion, the maker:

                                 ●    Is able to understand the information that is needed to make a decision about the above‑specified personal matter(s) and is unable to understand the options presented.   Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is able to retain the information that is relevant to making a decision about the above‑specified personal matter(s).
  
Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is able to identify and appreciate the consequences of making or not making a decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is able to communicate his/her decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

4.   I have attached a more detailed capacity assessment or report.  (Optional)    Yes      No

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of physician/                Printed name of physician/        
psychologist completing Part 1  psychologist completing Part 1 

Part 2

I,    (name and title/position of service provider)   , am a service provider.

The reason(s) I assessed the maker’s capacity are as follows:
                                                                                                               

I identified that an assessment of the maker’s ability to make personal decisions was warranted with respect to the following personal matters:          

Before conducting an assessment of the maker’s capacity, I determined that it was in the best interest of the maker to conduct the assessment, and met with the maker and explained to the maker the purpose and nature of the assessment.

I have interviewed the maker and determined that he/she has regained the capacity to make decisions about the following personal matter(s) of a non‑financial nature (check any or all that apply):

  health care
  accommodation
  with whom to live and associate
  participation in social activities
  participation in educational activities
  participation in employment activities
  legal matters
  other:_____________

The reason(s) for my determination are as follows:

1.   The level of consciousness of the maker at the time of my determination was (check one):
     
  alert
     
  fluctuating
     
  non‑responsive

2.   I have identified and ruled out any temporary medical conditions that may affect the maker’s capacity to make personal decisions:       Yes

3.   In my opinion, the maker:

                                 ●    Is able to understand the information that is needed to make a decision about the above‑specified personal matter(s) and is unable to understand the options presented.   Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is able to retain the information that is relevant to making a decision about the above‑specified personal matter(s).
  
Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is able to identify and appreciate the consequences of making or not making a decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

                                 ●    Is able to communicate his/her decision about the above‑specified personal matter(s).    Yes     No

         My reason(s) for this opinion are as follows:
                                                                                                               

4.   I have attached a more detailed capacity assessment or report.  (Optional):    Yes     No

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                                                               
Signature of service                           Printed name of service        
provider completing Part 2               provider completing Part 2   

AR 98/2008 s5

Schedule 7

Complaint to the Public Guardian
(section 24.2)

1.   Your contact information

                               (a)    What is your name, address, preferred telephone contact number and alternate telephone number (please state whether these numbers are for home, work, cell, pager or other), e‑mail address (if any), fax number (if any)? Please write in the space below.
                                                                                                

                              (b)    What is your relationship to the person who made the personal directive?
                                                                                                

2.   Information about the person who made the personal directive (if known):

                                       What is the maker’s name, address, preferred telephone contact number and alternate telephone number (please state whether these numbers are for home, work, cell, pager or other), e‑mail address (if any), fax number (if any)? Please write in the space below.
                                                                                                

3.   Information about the agent (person named in the personal directive to make decisions on behalf of the maker and who is the subject of your complaint) if known:

                                       What is the agent’s name, address, preferred telephone contact number and alternate telephone number (please state whether these numbers are for home, work, cell, pager or other), e‑mail address (if any), fax number (if any)? Please write in the space below.
                                                                                                

4.   Information about the personal directive

                               (a)    Do you have any other information about the personal directive (such as areas of agent’s authority to make decisions)?  If so, please write in the space below.
                                                                                                

                              (b)    What is the date when the personal directive was brought into effect (if known)?
                                                                                                

5.   Nature of your complaint

                               (a)    What are the details of your complaint, including dates or time periods and any steps you may have taken to resolve the matter? Please write in the space below.
                                                                                                

                              (b)    If you think this complaint requires the urgent attention of the Public Guardian and there is immediate concern about the safety of the maker, please explain why in the space below:
                                                                                                

                                       NOTE:  A complaint may only be made about a matter referred to in section 24.2 of the Personal Directives Act.

6.   People who can provide further information

                                       What are the full names, titles (if any), addresses and preferred telephone contact numbers and alternate telephone numbers of any person who may be able to provide further information about your complaint or about the maker’s circumstances? [optional].  Please write in the space below.
                                                                                                

                                       NOTE:  If the subject‑matter of your complaint could be an offence under the Criminal Code (Canada), abuse against a client under the Protection for Persons in Care Act or an offence under another statute or regulation of Alberta, the Public Guardian will refer the complaint to a police service or appropriate government ministry in accordance with s24.6 of the Personal Directives Act.

Dated at        (location)        in the Province of Alberta this        (day)        day of         (month)       ,         (year)       .

                                                                
Signature of Person Making Complaint

Your personal information is being collected under section 24.5 of the Personal Directives Act and will be used for the purposes of conducting an investigation or resolving a complaint under Part 4.1 of the Personal Directives Act, making a Court application under section 25 of the Personal Directives Act or as authorized or required under the Freedom of Information and Protection of Privacy Act or other enactment. If you have any questions about this collection, you may contact the Office of the Public Guardian at (780) 422‑1868.

AR 98/2008 s5