Nurse Apprentice Program ARPA Grant LPN Payment Request Date MM slash DD slash YYYY Approved Facilities(Required)Please select your facilityAlta Skilled Nursing and Rehabilitation CenterAlpine Skilled Nursing and Rehabilitation CenterBanner Churchill Community HospitalBattle Mountain General HospitalBoulder City HospitalCarson Tahoe HospitalCarson Tahoe Continuing Care HospitalCarson Tahoe Transitional Rehabilitation CenterCarson Valley Medical CenterDesert View HospitalGardnerville Health and Rehabilitation CenterGrover C Dils Medical CenterHarmon HospitalHearthstone of Northern NevadaHighland Manor of Elko - SNFHighland Manor of Fallon - SNFHighland Manor of Mesquite – SNFHorizon Health and Rehabilitation CenterHorizon Specialty Hospital of Las VegasHorizon Specialty Hospital of HendersonHumboldt General HospitalIncline Village Community HospitalKindred Hospital Las Vegas-Flamingo CampusKindred Hospital Las Vegas-Sahara CampusLas Vegas Post Acute and RehabilitationLas Vegas AMG Specialty HospitalLas Ventanas Retirement CommunityMesa View Regional HospitalMarquis Plaza RegencyMarquis Centennial HillsMount Grant General HospitalMountain View Health and Rehabilitation CenterNeuroRestorative RenoPahrump Health and Rehabilitation CenterPam Specialty Hospital of Las VegasPam Specialty Hospital of RenoNorth Las Vegas Care CenterOrmsby Post-Acute RehabPershing General HospitalRenown HealthRosewood Rehabilitation CenterSandstone Spring ValleySouth Lyon Medical CenterSt. Rose Dominican Siena Campus – Dignity HealthSt. Rose Dominican San Martin Campus – Dignity HealthSt. Rose Dominican Rose de Lima Campus – Dignity HealthSouthern Nevada Adult Mental Health Services (SNAMHS)Sierra Ridge Health and Wellness SuitesSpanish Hills Wellness SuitesWilliam Bee Ririe HospitalWingfield Skilled Nursing and Rehabilitation CenterIf 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 For those facilities that have timesheets in hours and minutes - use the conversion fields below to get your total decimal hours then enter that value in the required Total Monthly Hours belowHours RequestedEnter the total hours requested from your timesheetMinutes RequestedEnter the total minutes requested from your timesheetDecimal HoursEnter this value in Total monthly hoursNOTE: Time must be reported in decimal hours NOT hours.minutes. ( 1 hour 15 minutes = 1.25 hours ) Must match uploaded timesheets for the requested month See minutes to decimal hours chart hereMonth Submitted(Required)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear(Required)2022202320242025202620272028Total 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 validationName of Nursing School(Required)please choose the nursing schoolAntelope Valley CollegeArizona College/Las Vegas CampusCarrington CollegeChamberlain UniversityCollege of Southern NevadaGreat Basin CollegeGreat Basin College - PahrumpLas Vegas CollegeMojave Community CollegeNevada State CollegeNightingale CollegeSouthern Utah UniversityTruckee Meadows Community CollegeUnitek CollegeUniversity of Nevada, Reno (UNR)University of Nevada, Las Vegas (UNLV)Utah Tech University (Dixie)Western Governors UniversityWestern Nevada CollegeOtherOther Nursing School Please tell us where your student nurse is attending school so we can add it to the list.Enrollment StatusBy checking this box, you attest that the nurse apprentice is actively enrolled and in good standing in an accredited nursing program which is a mandatory requirement. YES CAPTCHA