Nursing Facility Training Grant Application

Nursing Facility Training Grant Application

Please submit one (1) application for each unique training activity.
Before submitting an application, please read the Nursing Facility Training Grant Program Guide and then proceed below.
To complete this application you will need the following information:
Nursing Facility/Employer Information
Note: Please provide the Nursing Facility/Employer Name and Address EXACTLY as it appears in the Ocean State Procures 'OSP' Vendor Portal.
Employer Name:*
Employer Address:*

Street Address

Street Address Line 2 (if needed)

CityState

Zip Code
Private Non-Profit CorporationPrivate For-Profit CorporationOther
Note: Government/Public entities are not eligible for this program.
Federal Employer Identification Number (FEIN):*
An employer identification number (EIN) is a nine-digit number assigned by the IRS. It's used to identify the tax accounts of employers and certain others who have no employees.
Primary Contact Person (for the purposes of this application): *

First NameLast Name
Contact's Title:*
ex: Director of Human Resources
Contact's Phone:*

Area CodePhone Number
Contact's E-mail:*
ex: sara.jones@work.com

Training Information
Please enter a short Name or Title for this training activity:*
ex: Cognitive Support Training
How many employees within the organization will be trained? *
ex: 15
Which employees within the organization will be trained?*
Please enter names and job titles or list the divisions/departments.
Anticipated Training Start Date:*

MonthDayYear
NOTE: Training may not start prior to the submission of the application and the submission of the application does not guarantee program approval. The GWB cannot reimburse for costs incurred prior to the issuance of a purchase order.
Anticipated Training End Date:*

MonthDayYear
Total Training Hours (per employee):*
ex: 40
Complete Name/Title of the Training Course, Program, or Conference:*
Name/Title of the Training Provider:*
Ex: Community College of Rhode Island
Please describe how the training will improve quality of care for patients with cognitive impairments.*
YesNo
If yes, please identify the certificate(s), qualification(s), or credential(s):
Please upload any attachments that further describe the training or curriculum.

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What is the total cost of the training?*
ex: $2,800.00
How was the total cost calculated?*
Please upload an activity budget and/or attachments that support the calculation of costs.

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Employer Attestations & Signature
I have reviewed the Nursing Facility Training Grant Program Guide and understand the program rules.*
Initial
The facility I represent is in compliance with the minimum staffing requirements outlined in Rhode Island General Laws section 23-17.5-32.*
Initial
My organization is registered as an approved RI state supplier in the Ocean State Procures 'OSP' system.*
Initial
The employee(s) I seek to train are authorized to work in the United States.*
Initial
The employee(s) I seek to train are W-2 employees of my organization and NOT 1099 independent contractors.*
Initial
The employee(s) I seek to train are being compensated at a rate of $15.00 per hour or more.*
Initial
By signing below, I attest that the information contained in this application is correct and accurate to the best of my knowledge.
Signature:*

Clear
Should be Empty:

Nursing Facility/Employer Information