Nurse Apprentice Program ARPA Grant LPN Payment Request

Date

Approved Facilities(Required)

If your facility is not listed, please contact us. An established Nursing Apprentice Program is required.

Requestor(Required)

First Last

Requestor Email(Required)

Nurse Apprentice Name(Required)

First Last

Month Submitted(Required)

Year(Required)

Total monthly hours(Required)

Acute Hours(Required)

For those facilities that have both SNF and Acute - please report the hours worked in each department (must match the total monthly hours reported)

SNF Hours(Required)

Upload Timesheet(Required)

Max. file size: 16 MB.

Required for validation

Name of Nursing School(Required)

Other Nursing School

Please tell us where your student nurse is attending school so we can add it to the list.

Enrollment Status(Required)

By checking this box, you attest that the nurse apprentice is actively enrolled and in good standing in an accredited nursing program. This is a mandatory requirement.

YES

Clinical Skills Checklist(Required)

By checking this box, you attest that the nurse apprentice has provided a clinical skills checklist from their nursing program and an updated copy is on file. This is a mandatory requirement.

YES

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