Vulnerable Sector Screen Guideline
Date of original approval: March 20, 2019 by HUEC
Date of last approved revision: May 22, 2024 by HUEC
1. Purpose
The purpose of this Guideline is to ensure the review, in a timely manner, by a Faculty-level expert panel of any instance where a Vulnerable Sector Check (VSC), Criminal Record Check (CRC), self-disclosure, annual attestation and/or notification by the University of Toronto Office of Safety and High Risk returns a positive result. A result is considered positive when it indicates any criminal conviction or outstanding charge that has not already been addressed through this Guideline.
2. Application and Scope
This Guideline applies to learners in the following Temerty Medicine programs:
- MD (Undergraduate Medical Education), including MD/PhD
- Medical Radiation Sciences
- Physical Therapy
- Physician Assistant
- Postgraduate Medical Education
The Expert Panel is advisory, with its recommendations initiating and informing action through the appropriate progress/professionalism guideline or procedure. As described below, the role of the Expert Panel is to assess whether a learner’s participation in a current or future clinical placement poses a safety risk or other risk related to professional conduct.
The Temerty Medicine Board of Examiners is normally the final decision-making body with respect to Expert Panel recommendations regarding a learner’s registration status, progression and/or learning plan for MD, MD/PhD, Medical Radiation Sciences, Physician Assistant, and Postgraduate Medical Education learners.
Relevant University of Toronto polices include but are not limited to the Standards of Professional Practice Behaviour for all Health Professional Students, Code of Student Conduct, Policy on Sexual Violence and Sexual Harassment, Supportive Leaves Policy, and other University policies, standards, guidelines or procedures for assessing academic progress.
Relevant Temerty Medicine guidelines include but are not limited to the MD Program Guidelines for the Assessment of Student Professionalism and Guidelines for the Assessment of Postgraduate Residents.
This Guideline does not replace or limit the legal and ethical standards established by professional or regulatory bodies; the policies and procedures at clinical placement sites; or by other applicable University or Faculty policies, standards, guidelines or procedures.
3. General Vulnerable Sector Screening Requirements
Vulnerable sector screening is normally required for individuals undertaking volunteer, training, or work in positions of trust or authority over children, seniors, or other vulnerable persons. Informed by an amendment to the Police Record Checks Reform Act (2015), vulnerable sector screening may involve one or more of the three types of checks provided by the Ontario’s policies services: VSC, CRC, and Criminal Record and Judicial Matters Check .1
In general, a VSC and/or CRC is required of Temerty Medicine learners in the programs named above upon admission/entry, and every five years thereafter, with self-disclosures required in interim years. Learners in those programs are required to immediately self-disclose to the Faculty any changes to their VSC or CRC status, including new criminal charges or convictions that have not already been addressed through this Guideline.
Each program named above will determine and make available to learners the specific vulnerable sector screening registration requirements for their program, which are informed by the general requirements outlined above. Learners must comply with their program’s vulnerable sector screening registration requirements; failure to do so is considered unprofessional and will be addressed through the appropriate conduct/professionalism policy, guideline or procedure.
4. Review Process
a. Initiation
The review process described in this Guideline is initiated in any instance where Temerty Medicine becomes aware of a learner’s criminal conviction or outstanding charge that has not already been addressed through this Guideline.
b. Initial Assessment: Procedural Jurisdiction
The program leader (Associate Dean or Director) of the applicant's/learner's program is responsible for conducting an initial assessment of the situation to determine if an Expert Panel should be convened. This initial assessment should also consider if another University or clinical placement site policy, guideline or procedure should be invoked in conjunction with or in place of this Guideline.
To make this initial assessment with respect to procedural jurisdiction, the program leader (Associate Dean or Director) will consult at a minimum with University of Toronto Legal Counsel and may consult with other education and administrative leaders as necessary. Confidentiality will be maintained, and information will only be shared on a need-to-know basis.
c. Expert Panel: Membership
If it is determined that an Expert Panel should be convened, the program leader (Associate Dean or Director) of the applicant's/learner's program will act as Chair of the Panel.
Core membership of the Panel is comprised of the following individuals or delegates/representatives:
Voting:
- Associate Dean, MD Program
- Associate Dean, Postgraduate Medical Education
- Director, Medical Radiation Sciences Program
- Director, Physical Therapy
- Director, Physician Assistant
- Director of Enrolment Services & Faculty Registrar
- Manager, Admissions & Registration, PGME
- Vice-President Education or equivalent/delegate from the learner’s clinical placement site at the time the Panel is convened and, where applicable, pending clinical placement site
Non-voting:
- Associate Dean, Learner Affairs
- MD-PGME Faculty Lead in Ethics & Professionalism
- Legal Counsel, Office of University Counsel
In accordance with University-Hospital Affiliation Agreements, the Vice-President Education or equivalent/delegate from each affiliated hospital will be invited to attend Panel meetings. Scheduling priority will be given to the Vice-President Education or equivalent/delegate from the learner’s clinical placement site at the time the Panel is convened and, where applicable, pending clinical placement site, will participate as core voting members. Other Vice-President Educations or equivalents/delegates will participate as non-voting members.
At the discretion of the Chair, additional members (e.g. Vice Chair, Education; Program Director; Course Director; Office of Inclusion & Diversity representative) may be invited to participate in Panel discussions as non-voting members to provide further subject matter expert opinions on complex situations or specific training program requirements.
d. Expert Panel: Role
The Expert Panel is advisory, with its recommendations initiating and informing action through the appropriate progress/professionalism guideline or procedure.
In general, the role of the Expert Panel is to assess whether a learner’s participation in a clinical placement poses a safety risk or other risk related to professional conduct. More specially, the role of the Panel is to:
- Provide advice regarding admission decisions, training, or practice for relevant Temerty Medicine health professional applicants/learners identified as having a positive VSS, CRC, self-disclosure or attestation.
- Make determinations about and advise on whether information disclosed in an applicant’s/learner’s VSS, CRC, self-disclosure or attestation impacts their appointment or registration status at the University, including monitoring plans.
- Consider appropriate supports available to the learner.
- Recommend communications plans to report to relevant and appropriate administration, hospital partners and/or regulatory bodies.
In making its assessment, the Expert Panel will apply an equity, diversity and inclusion lens and take into account a learner’s lived experiences.
e. Confidentiality
Confidentiality will be maintained, and information will only be shared on a need-to-know basis and in accordance with University policy and any relevant affiliation agreement(s) and/or applicable law.
In accordance with University-Hospital Affiliation Agreements, all learner information disclosed to the Expert Panel shall be:
- anonymous,
- treated as highly confidential,
- not be used for any other purposes other than to complete the assessment, and
- destroyed at the completion of the assessment, though a confidential summary may be maintained to evidence that an assessment occurred.
f. Quorum and Decision-making
Quorum consists of at least four members of the Expert Panel core membership, including the Chair as well as the Vice-President Education or equivalent/delegate from the learner’s clinical placement site at the time the Panel is convened and, where applicable, pending clinical placement site.
Generally, the Panel’s recommendations are arrived at by consensus following discussion. When consensus is not established, the Chair may choose to call a vote, with a simple majority of the voting members present deciding the matter. The Chair will only vote in order to break a tie.
g. Communication with Learner
If it is determined that an Expert Panel should be convened, the Chair will inform the learner by email and provide them with the opportunity to provide a written submission and/or other documentation for consideration by the Expert Panel. Learners may consult with legal counsel prior to providing a written submission/documentation. This material should be submitted to the Chair by email no longer than 15 days following notification to the learner from the Chair that an Expert Panel will be convened. Reasonable efforts will be taken to ensure that the submission/documentation provided to panel members is adapted to protect the learner’s anonymity.
The Chair of the Expert Panel will communicate the panel’s recommendation to the learner, copied to the office/individual responsible for managing the appropriate progress/professionalism guideline or procedure. If a recommendation is made to disallow a learner to participate in a clinical placement at an affiliated health care site, the communication to the learner will include the supporting rationale.
h. Administrative support
Administrative support for a Panel meeting will be determined by the program leader (Associate Dean or Director) of the applicant’s/learner’s program.
i. Accountability and Reporting Relationship
The Panel is advisory to the relevant program leadership and ultimately to the Dean of Medicine, who will act on the Panel’s recommendations in accordance with the appropriate policy, standard, guideline or procedure.
1 The Ontario Provincial Police publishes information on its website about the difference between the Criminal Record Check and the Vulnerable Sector Check. Generally speaking, the VSS is more detailed as it checks a greater number of sources. http://www.opp.ca/ecms/index.php?id=499