Nurse Apprentice Program ARPA Grant – Salary Request

Nurse Apprentice Program ARPA Grant Salary Request

Date Submitted

MM slash DD slash YYYY

Facility(Required)

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

Requestor(Required)

First Last

Requestor Email(Required)

Month Submitted(Required)

Year(Required)

Nurse Apprentice Name(Required)

First Last

Is the student an RN or LPN apprentice?(Required)

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.

Hours Worked

For those facilities that have both SNF and Acute - please report the hours worked in each department.

Apprentice worked in which type of setting?(Required)

Acute Care

Skilled Nursing (SNF)

Acute Hours(Required)

SNF Hours(Required)

Total Monthly Hours(Required)

This field is auto-calculated. Enter hours in the adjacent "Acute Hours" and/or "SNF Hours" field(s).

Upload Timesheet(Required)

Required for validation

Drop files here or

Max. file size: 20 MB.

State Facilities Only(Required)

The Nurse Apprentice Program ARPA Grant provides reimbursement of an hourly rate of $3.00 for the Registered Nurse supervising the Nurse Apprentice. This is included in the hourly reimbursement calculations based on the hours worked by the apprentice.

If your hospital elects not to receive this reimbursement, please indicate your decision below.

OPT-IN: Our hospital elects to receive the reimbursement.

OPT-OUT: Our hospital elects NOT to receive the reimbursement for the supervising nurse.

Have you provided NRHP with a current copy of the student's skills list from their school?(Required)

No - I need to provide an updated list

Yes - I have already provided one for the current term

Upload Skills List(Required)

Please upload a copy of the recent skills checklist provided by the nurse apprentice's school.

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 20 MB.

When is the apprentice expected to graduate?(Required)

MM slash DD slash YYYY

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

CAPTCHA