PROFESSIONAL DEVELOPMENT SVC/PRO TECH REIMBURSEMENT FORM

This form covers professional development activities completed the current year. Activities completed in the previous year cannot be reimbursed after the December 31st of that year.

(Activities completed in the current year and paid for in the previous can still be reimbursed using this form. For example, if you paid for CEU credits in 2020 but did not complete all credits till 2021 you can still receive reimbursement from your 2021 benefit based on your eligibility).

*If you a registered nurse requesting reimbursement for your RN Specialty Certification please use this form:

https://www.tfaforms.com/4747436

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

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

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

Supporting Documents are necessary before continuing:

Proof of Payment/Cost: 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: 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.

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.

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.

For Licensure: You must submit documents showing proof of payment. Your proof of payment must show the payment and a copy of your license info showing a renewal.

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.

You must have your supporting documentation ready for upload before continuing.

I have my supporting documentation ready to upload with my request

This form covers activities completed this year. Activities completed in the previous year cannot be reimbursed after the 12/31 deadline.

(for example: Activities completed in 2021 but paid for in 2020 can be reimbursed using this form as well as any activity completed in 2021 and paid for in 2021.)

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

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

Department

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

Job Title

Bargaining Unit

Current FTE

Date of Hire (mm/dd/yyyy format)

Professional Development Activity Information

Date of Professional Development Purchase (mm/dd/yyyy format)

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).

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/license you are requesting be reimbursed)

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

Type of professional development activity

Other professional development activity

For Certification Exams/Fees - did you earn your certification

Start date of membership or certification or licensure

End date of membership or certification or licensure

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

For Professional Licensure Fee :
You must submit documents showing proof of payment. Your proof of payment must show the payment and a copy of your license info showing a renewal.

Supporting Documentation

After you submit the form, within a few minutes, you will receive an email from SEIU 1199NW Training Fund via Conga Sign (please check you junk/spam for this). That email has a blue 'View Document' button to click at which point you will begin the electronic signing process. Click here for a walkthrough of the signing process you can review.

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.