Expense Reimbursement

CNA Earn and Learn Program
Expense Reimbursement Request Form

This form is to request reimbursement for expenses associated with training and certification for an individual CNA trainee. Whenever possible facilities are encouraged to support CNAs by paying costs that could be an obstacle to a trainee in completing the certification process. Eligible expenses must be based on the actual cost associated with supporting and training the specific CNA trainee named on this form.

Facility/Trainee Information

Name of Participating Facility

Facility Mailing Address (street, city, zip)

Name of CNA Trainee

Dates of Participation

Eligible Expenses
List eligible expenses on a per student basis - a separate reimbursement request must be submitted for each CNA trainee. Please provide the amount of each eligible expense, the total of all expenses, and also the total reimbursement requested (maximum of $4000 per CNA trainee). Receipts are not required to be submitted, but AHHA reserves the right to request detailed accounting and receipts. For costs shared among multiple CNA trainees, calculate a per student cost.

CNA Trainee wages/benefits

In-house CNA training (per student cost)

External CNA training program tuition & fees

CNA training supplies per student (stethoscope, blood pressure cuff, etc.)

Training textbook/workbooks

BLS/CPR training

Background check/fingerprinting/drug screen

Certification license and exam fees

TOTAL AMOUNT of expenses

TOTAL AMOUNT reimbusement requested ($4,000 max)

Current Status of CNA Trainee

Check all milestones met by CNA trainee so far:

Other:

Training Report/Success Story

Please provide a few sentences on CNA trainee’s experience and success with the program.

I certify/attest that the above expenses were incurred and paid by our facility and, if requested, I will provide back-up documentation.

Signature of facility representative

Name

Title

Date

Thank you for your submission!

CNA Earn and Learn Program Expense Reimbursement Request Form

CNA Earn and Learn Program
Expense Reimbursement Request Form