Nurse Apprentice Program ARPA Grant RN 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

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 below

Hours Requested

Enter the total hours requested from your timesheet

Minutes Requested

Enter the total minutes requested from your timesheet

Decimal Hours

Enter this value in Total monthly hours

NOTE: 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 here

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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