CNA Earn & LearnReimbursement Request

CNA Earn & Learn

Reimbursement Request

This form is to request reimbursement for expenses associated with training and certification for an individual CNA trainee. 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*

Mailing Address

Name of CNA Trainee*

Eligible Expenses

List eligible expenses to be reimbursed 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 $3000 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.

In-house Training cost per trainee

External CNA Training Program Tuition & Fees

Training Expenses

CNA Training Supplies

Training Textbooks

BLS/CPR Training

Background Check /Fingerprinting /Drug Screen

Certification License and Exam Fees

Trainee Travel

Trainee Lodging

Total*

Current Status of CNA Trainee

Check all milestones met by CNA trainee so far.

Enrolled in CNA Training

Completed CNA Training

Paperwork Submitted for Licensing

Took CNA Exam

Passed CNA Exam

Employed at Facility as CNA

Other

Training Report / Success Story

Success Story*

Please provide a few sentences about the CNA trainee's experience and success with the program.

Name of person submitting form*

Title*

Email Address*

Date*

File Upload

If needed, supporting documentation can be uploaded here.

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