HR HealthCheck

Vaccination Directive for Hospitals and Other Health Care Settings Issued by Ontario Chief Medical Officer of Health

HR HealthCheck

Vaccination Directive for Hospitals and Other Health Care Settings Issued by Ontario Chief Medical Officer of Health

Date: August 18, 2021

On August 17, 2021, the Ontario Chief Medical Officer of Health issued Directive #6 COVID-19 Vaccine Policy in Health Care Settings (Directive) regarding the implementation of a mandatory vaccine policy for employees, staff, contractors, volunteers and students in certain health care settings.

The Directive has been issued with a view to protecting vulnerable patients and staff in settings where there is a higher risk of transmitting or contracting COVID-19 (in particular, the Delta variant).

In this HR Healthcheck, we review the Directive and its requirements for the applicable organizations.

Which organizations does the Directive apply to?

The Directive applies to the following organizations (collectively, Covered Organizations):

  • Public hospitals within the meaning of the Public Hospitals Act
  • Service providers within the meaning of the Home Care and Community Services Act, 1994, with respect to their provision of community services to which that Act applies
  • Local Health Integration Networks within the meaning of the Local Health System Integration Act, 2006, operating as Home and Community Care Support Services with respect to the provision of community services and long-term-care placement services
  • Ambulance Services within the meaning of the Ambulance Act, 1990, with respect only to paramedics.

Requirement for proof of vaccination and antigen point-of-care testing

The Directive requires that the Covered Organizations establish, implement and ensure compliance with a COVID-19 Vaccination Policy (Policy) for employees, staff, contractors, volunteers and students (collectively, Covered Individuals). Under the Policy, a Covered Individual must provide:

(a) proof of full vaccination against COVID-19, or

(b) written proof of a medical reason from a physician or registered nurse in the extended class (e.g. Nurse Practitioner) that sets out a documented medical reason for not being fully vaccinated against COVID-19, and the effective time period for the medical reason, or

(c) proof of completing an educational session approved by the Covered Organization about the benefits of COVID-19 vaccination prior to declining vaccination for any reason other than a medical reason; at a minimum, the session must address how the COVID-19 vaccines work and their benefits, vaccine safety, the risks of not being vaccinated and the possible side effects of the vaccine.

A Covered Organization may remove the option of requiring proof of completion of an educational session (paragraph (c)) from its Policy and instead require Covered Individuals to provide either proof of full vaccination (paragraph (a)) or written proof of a medical reason for not being fully vaccinated (paragraph (b)). Where it removes this option, the Covered Organization must still make available an educational session that satisfies the requirements of paragraph (c) to the Covered Individuals. 

Where a Covered Individual does not provide proof of being fully vaccinated but relies on the medical reason described in paragraph (b) or, if applicable, the educational session described in paragraph (c), that Covered Individual must submit to regular antigen point-of-care testing and demonstrate a negative result at a minimum of once every seven (7) days. The verification of the test result must be in a form determined at the discretion of the Covered Organization. The Ontario government has provided guidance for organizations implementing regular antigen point-of-care testing.

Any businesses or entities operating on the site of a Covered Organization which is a public hospital must also comply with the Policy.

Under the Directive, every Covered Organization must collect, maintain and disclose statistical (non-identifiable) information about the number of Covered Individuals who provided proof of being fully vaccinated, those who provided proof of a medical exemption and those who completed an educational session under paragraph (c) (where applicable), together with the total number of the Covered Individuals to whom this Directive applies. The information may be disclosed to the Ministry of Health, upon request, and may be made public.

Effective date of implementation

The requirements of the Directive are to be implemented by September 7, 2021.

Going forward for the Covered Organizations

For those organizations that already have vaccination policies in place, it is recommended that you ensure those policies align with this Directive.

Consideration will need to be given to operationalizing the Directive including, among many other things, whether to remove the option of requiring proof of completion of an educational session (paragraph (c)) from your Policy, as well as decisions about how the antigen testing will be implemented, such as hours of operation and staffing, and how and when the educational sessions will be offered.

Your Hicks Morley lawyers will be able to assist you with the practical and legal implications related to implementation.


The article in this client update provides general information and should not be relied on as legal advice or opinion. This publication is copyrighted by Hicks Morley Hamilton Stewart Storie LLP and may not be photocopied or reproduced in any form, in whole or in part, without the express permission of Hicks Morley Hamilton Stewart Storie LLP. ©