NURSE PROFESSIONAL DEVELOPMENT REIMBURSEMENT FORM

This form covers RN Specialty Certification/Recertification and Professional Development activities completed in the current year. Activities completed in the previous year cannot be reimbursed after December 31st of that year.

(Activities completed in the current year and paid for in the previous year can be reimbursed using this form. For example, if you paid for your certification exam in 2020, but did not take the test till 2021 you can still use this form to be reimbursed out of your 2021 benefit based on your eligibility).

NOTE: PER DIEM & CONTRACT EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

For program details, eligibility, specialty nurse areas, what activities can be reimbursed, and other details, please visit the professional development page of our website.

Supporting documentation is necessary:

Proof of Payment/Costs: Please submit 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: This must show that whatever activity you have paid for has been completed entirely.

Examples:

For specialty certification, please include a copy of your certification or a letter from the certifying organization recognizing your certification/re-certification.
If you paid for 14 Continuing Education Units (CEUs) and submit only 2 completed CEUs we will not be able to reimburse you. Or if you paid for a conference where you will obtain CEUs, we can only reimburse you after proof is provided that you obtained the CEUs

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

4. For Membership renewals: PER the Board of Trustees your Training Fund NO LONGER requires proof of CEUs obtained during your membership period. You membership is still required to provide access to CEUs - but we will no longer need proof you have obtained them.

5. For Exams: You DO NOT have to pass your exam to be reimbursed! In the case you are needing reimbursement for an exam that you did not pass, you need only send us the proof of payment/costs and proof you took the exam from the organization (a copy of your test results will usually suffice along with a receipt of payment).

If you have any questions please email members@healthcareerfund.org or call 425-255-0315. If you need help uploading documents, please visit our Help with Online Tools page.

The standard processing time once all standard backup documentation received is 30 Days.

You must have your backup documentation ready to upload before continuing.

Yes I have my backup documentation ready to upload

This form covers RN Specialty Certification/Recertification and Professional Development activities completed in the current year. Activities completed in the previous year cannot be reimbursed after December 31st of that year.

(Activities completed in the current year and paid for in the previous year can be reimbursed using this form. For example, if you paid for your certification exam in 2020, but did not take the test till 2021 you can still use this form to be reimbursed out of your 2021 benefit based on your eligibility).

EMPLOYEE INFORMATION (your name should match what your employer has, 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 (please be sure you DO NOT share this email with another hospital worker such as a family/friend/co-worker/spouse/child - each person needs to have their own email and you can always use your work email if you don't have a personal email)

Employer

Worksite Location/Campus (if not at a main hospital bldg. ex. SMC Capital Hill, VMC Kent Clinic, Lidgerwood KP, etc.)

Department

Job Title

Bargaining Unit

Current FTE

Date of Hire (mm/dd/yyyy format)

Professional Development Activity Information

Date Purchased/Paid For

I am requesting reimbursements for

Description of purchase (this would be the title of any books/courses providing CE credits, the name of the certification you earned, the name of the conference you attended, or the name of the professional membership you are requesting be reimbursed)

For Certification Exams/Fees - did you earn your certification

Start date of certification or membership

End date of certification or membership

Date of Completion (your activity must be completed for us to reimburse it. For any activity providing CEUs you must have completed/obtained all CEUs. For certifications or exams you must have your exam results or confirmation that you have taken the exam or obtained the certification.)

Sponsoring school or organization (this would be the name organization that is on the receipt whom you paid for the activity described above)

Total dollar amount requested (no $ sign please, just the numbers. Ex. "220.25")

No $ necessary

Lead Source

Record Type

Opportunity Name

Opportunity Stage

Required Supporting Documentation:

For CEUs/Courses/Conferences:
You must submit 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 events, etc.)

For Exams/Certifications:
You 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. You may be reimbursed for your exam costs regardless of whether you pass or fail.

For Study/Review Materials:
You 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:
You 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.

Backup Documentation

On the Next Page you will be able to review everything you are about to submit to the Training Fund. Please be sure your contact information is accurate and the supporting documentation has been uploaded. When you have submitted your request, within a few minutes, you will receive an email from SEIU 1199NW Training Fund via Conga Sign to sign your funding request. If you do not receive that email (it may go to junk or spam) or have any questions about the electronic signing process please contact us at 425-255-0315 or members@healthcareerfund.org.

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.

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PRIVACY POLICY

• https://healthcareerfund.org/wp-content/uploads/2018/08/Final-confidentiality-statement.pdf

• Please Note that in completing the attached "Application," you are also agreeing to the following statement:

I have had the opportunity to read and review the SEIU Healthcare 1199NW Training Fund Privacy Policy. By filling out and submitting this Application/Intake Form, I agree to this Privacy Policy and authorize the Training Fund to contact, or my behalf, current or previous employers or educational institutions, or other relevant entities, to obtain information that may be necessary for the administration of the Training Fund's benefits. I further understand this authorization is on-going for the purposes of administering the Training Fund's benefits.

I agree

DATA SHARING WITH LABOR MANAGEMENT PARTNERS

The SEIU Healthcare 1199NW Training Fund provides specific details about active members' usage of Training Fund programs and services to both employer and labor partners. Sharing this information allows labor/management partners to do more targeted workforce planning, and also support individuals in their career and programmatic path. Data that we share does not include Date of Birth and Social Security Number.

Do you agree to allow the Training Fund to share your information with employer partners:

Do you agree to allow the Training Fund to share your information with SEIU Healthcare 1199NW:

TEXT MESSAGING POLICY

Your education and career advancement and training opportunities are important to us. In order to provide you with the up-to-date-service, we occasionally send text messages to our members about their education and training benefits and services. Standard text messaging rates apply.

By completing this form, you authorize text messaging from Fund unless you decline text messaging. To decline Text Messages, email your Regional Education Navigator or members@healthcareerfund.org stating that you do not want to receive text messages.

You can decline text messages at any time. Under some circumstances this may delay your receiving information on your program(s). Please talk with your Navigator (if you don’t have one, one will be assigned on submittal of this form) if you have questions on text messaging.

PHOTO/VIDEO USE POLICY – TRAINING FUND EVENTS

The ability to communicate about Training Fund services to our members and to use information gathered in classes and sessions for further training is important to the Training Fund.

Unless you decline photo/video by the Fund, by completing this form you authorize and agree that the SEIU Healthcare 1199NW Multi-Employer Training & Education Fund and SEIU Healthcare 1199NW may use photographic images or video footage of you, or in which you are included, taken during Training Fund related classes, sessions, or events, for public relations, program marketing, electronic media, or educational purposes.

To opt out from photo/video use, please send a separate email your Regional Education Navigator or members@healthcareerfund.org stating that you do not want your images/video to be used for Training Fund purposes.

You may opt out of photo/video use at any time. Please talk with your Navigator (if you don’t have one, one will be assigned on submittal of this form) if you have questions on photo/video use.

NON-DISCRIMINATION POLICY STATEMENT

The Training Fund is dedicated to equal opportunity education and training. It does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, physical or mental ability, veteran status, military obligations, background, or marital status.