FY 24/25 Adult Certification Voucher Request Form

FY 24/25 Adult Certification Voucher Request Form

To view and/or download a list of approved certifying bodies

and their corresponding certifications, select the link below.

ABSNC

NCCA

ISO

ICAC

You cannot fill this form out for yourself.

Certification submissions must be filled out by the leader of your home department.

Approved leaders include Managers, Directors, or above.

We cannot accept submissions from Charge Nurses, CSLs, Asst. Managers, etc.

VUMC supports certifications, but not certifications

that are required based on a job description.

For questions or concerns related to your submission,

contact Nursingcertification@vumc.org

I confirm that I am the VUMC leader listed above.*

Select

Payment Information

The funds to reimburse the certified nurse are budgeted and paid from the unit, department, or clinic budget.

Please ensure you are inputting your department information and not the name of the employee.

What is the email of the departments point of contact for payment of the voucher?*

Certification Voucher Request

Please select the certifying body:*

Select

If other, please enter type out the full name certifying body and certification type.

Please select the type of certification:*

CCRN (Adult) Acute/Critical Care Nursing

CCRN-K (Adult) Acute/Critical Care Knowledge Professional

CCRN-E (Adult) Tele-ICU Acute/Critical Care Nursing

CMC (Adult) Cardiac Medicine

CSC (Adult) Cardiac Surgery

PCCN (Adult) Progressive Care Nursing

PCCN-K (Adult) Progressive Care Knowledge Professional

Please select the type of certification:*

Certified Emergency Nurse (CEN)

Certified Flight Registered Nurse (CFRN)

Certified Transport Registered Nurse (CTRN)

Trauma Certified Registered Nurse (TCRN)

Please select the type of certification:*

Blood & Marrow Transplant Certified Nurse (BMTCN)

Certified Breast Care Nurse (CBCN)

Certified Pediatric Hematology Oncology Nurse (CPHON)

Oncology Certified Nurse (OCN)

Advanced Oncology Certified Nurse Practitioner (AOCNP)

Please select the type of certification:*

Certified Neuroscience Registered Nurse (CNRN)

Stroke Certified Registered Nurse (SCRN)

Employee Information

Employee's First Name*

Employee's Last Name*

Employee's Hire Date*

Employee's Email Address*

Please select the entity where employee primarily works.*

Select

If other, please specify*

Enter the home department for employee*

What type of certification request are you submitting for?*

Select

Has this employee been in the Nurse Residency Program at VUMC within the last 36 months?*

Yes

Certification Review Course Information

Did the employee attend a certification review course related to the requested certification exam?*

Yes

When did the employee attend the onsite review course?*

Please select where the employee attended the review course:*

VUMC Sponsored Review Course (Onsite or Virtual)

Non-VUMC Sponsored Review Course

Has the employee successfully completed his/her probationary period?*

Yes

Ineligible*

Due to the response selected, the employee is not eligible for reimbursement at this time.

Successful completion of the probationary period has to be completed prior to applying for any type of nursing specialty certification exams.

Please refer to Policy Number OP 10-10.49 within Policy Tech for further information.

Yes, I Understand

Is the employee full time (>30hours)?*

Yes

Ineiligble*

Due to the response selected, the employee is not eligible for reimbursement at this time.

Staff must be employed full time (30 hours per week or greater) in order to apply and/or be reimbursed the cost of any approved nursing specialty certification exam.

Please refer to Policy Number OP 10-10.49 within Policy Tech for further information.

Yes, I understand

Is the employee currently on a Performance Accountability and Commitment plan?*

Yes

Ineiligble*

Due to the response selected, the employee is not eligible for reimbursement at this time.

An employee must not be on a Performance Accountability and Commitment plan in order to apply and/or be reimbursed the cost of any approved nursing specialty certification exam.

Please refer to Policy Number OP 10-10.49 within Policy Tech for further information.

Yes, I understand

Is the certification relevant to the current practice for the employee?*

Yes

Ineligible*

Due to the response selected, the employee is not eligible for reimbursement at this time.

The course must be relevant to the employee's current practice in order to apply and/or be reimbursed the cost of any approved nursing specialty certification exam.

Please refer to Policy Number OP 10-10.49 within Policy Tech for further information.

Yes, I understand

Finalizing Submission

Please select "I agree" confirming the staff member you are submitting this form for can receive a voucher/code from the VUMC Certification Team or directly from an approved certifying body.*

I agree

Please type your name agreeing to the statements below:*

The Manager/Leader agrees to reimburse NEPD the full cost of the requested certification exam(s).

The Manager/Leader agrees that all employee(s) meet the reimbursement requirements according to Policy Number OP 10-10.49.

Send me a copy of my responses

Leader Information

Payment Information

Certification Voucher Request

Employee Information

Certification Review Course Information

Voucher Eligibilty

Finalizing Submission