PROFESSIONAL DEVELOPMENT SVC/PRO TECH REIMBURSEMENT FORM

Professional/Technical and Service/Maintenance/LPN Professional Development Reimbursement Form.

Standard processing time once all standard backup documentation received - 30 Days

Eligibility:

Employees in the Professional/Technical and Service/Maintenance/LPN bargaining units who have passed their probationary period (generally 90 days) at the time of purchase of their Professional Development activity.

Benefit:

The Professional Development benefit provides up to $300 per calendar year based on FTE. Employees with an FTE of 0.75 or above are eligible for up to 100% of the $300 per year. Employees with an FTE of 0.5- 0.74 are eligible for 75% of $300 or $225. Employees with an FTE of 0.49 or below may receive 50% of $300 or $150.

What is covered:

Courses and registration for courses that carry CEU credits as well as required books or media related to a CEU course taken.
National certification exams or courses/review materials that prepare participants for those exams.
Membership in professional organizations that provide access to CEUs as a benefit of membership. Restrictions apply. See instructions below*

Backup Documents Necessary before moving forward:

Proof of Payment/Cost (the detailed invoice/receipt from the organization listing the total amount you paid, the goods/services you paid for, your name, the organizations name, and the date paid).
Proof of Completion (the completion has to show whatever activity you have paid for has been completed entirely. Example: if you paid for 14 CEU's and submit only 2 completed CEU's we will not be able to reimburse you. Example: if you paid for a conference where you will obtain CEU's, we can only reimburse you after proof is provided you obtained the CEU's.)

For Study Materials/activities that are not providing CEU's directly: there is no proof of completion needed, just proof you received the materials, and proof of payment/costs.

For Membership renewals: If we have previously reimbursed you for a membership and you are submitting for a renewal fee, you must provide proof that you earned CEU's with that organization, during the previous membership period. Example: if we reimbursed you for a two year membership from 1/1/2017 - 1/1/2019 and you are renewing it, you would need to provide proof that you obtained CEU's from the membership organization between 1/1/2017 and 1/1/2019 - the period we initially reimbursed you for.

If you have any questions please email prodev@healthcareerfund.org or call 425-255-0315.

Under penalty of perjury, I state that the information provided is correct. By signing this form, I approve the Training Fund to issue funding on my behalf.

EMPLOYEE INFORMATION: For your name please give us the full first and last name your employer has on file, no nicknames please.

First Name

Middle Initial

Last Name

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal

Preferred Phone Number

Mobile Phone

Work Phone

Home Phone

Primary Email

Email

Employer

Department

Job Title

Bargaining Unit

Current FTE

Date of Hire

Professional Development Information

Date of Professional Development Purchase

Description of purchase

Sponsoring school or organization if applicable

Type of professional development activity

Other professional development activity

Total dollar amount requested (no "$" needed, just enter in the numbers and any cents, eg. "220.25")

Lead Source

Record Type

Opportunity Name

Opportunity Stage

IMPORTANT NEXT STEPS!

You will receive an email with instructions on obtaining your manager's approval. Please follow the instructions and return to the Training Fund. Your manager's approval must be received in order to process your request.

Manager's First Name

Manager's Last Name

Manager's Title

Manager's Email

Manager's Phone Number

Contact Record Type

Required Back-Up Documentation:

For CEUs/Courses/Conferences:
Must submit back up documents showing proof of payment and attendance/completion. Your proof of payment must include your name, the name of the sponsoring organization that was paid, the amount paid and the date paid. Your materials must also demonstrate that you not only paid for but actually took the course/CEUs or attended the conference. (Examples may include CEU certificates, sign-in sheets from event, etc.)

For Exams/Certifications:
Must submit documents showing proof of payment and completion of the exam/certification. Your proof of payment must include your name, the name of the sponsoring organization that was paid, the amount paid and the date paid. Your materials must demonstrate that you not only paid for, but actually completed the exam/certification. Your benefit will pay for your exam costs regardless of pass/ fail outcome.

For Study/Review Materials:
Must submit documents showing proof of payment. Your proof of payment must include your name, what you purchased, the amount paid, and clearly illustrate what the purchase was for (if not obvious from title of materials.)

For Professional Memberships:
Must submit documents showing proof of payment. Your proof of payment must show that the membership is in your name, the name of the sponsoring organization that was paid, the amount paid and the date paid. *NOTE: If you’re requesting reimbursement for a professional membership that the Training Fund has paid for in a prior year, you must include proof of CE activity with that organization in order to have your membership paid again.

Backup Documentation