Effective 5.2.16

Training Funds Application

Section 1: Organization Information

Please note: It is a requirement to have completed Phase 2 in the contracting process in order to submit an application for funds.

Please check with the PPS Lead Contact in your organization or inquire at DSRIPWorkforce@ahihealth.org.

Organization Name:

Address:

Contact Person/Title:

Email address:

Phone:

Is your organization a Safety Net Provider?

☐ YES ☐ NO Unsure? Check with your organization’s PPS Lead or review the definition at: http://www.health.ny.gov/health_care/medicaid/redesign/docs/safety_net_definitions.pdf

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Effective 5.2.16

Please complete sections 2 and 3 for EACH training that funding is being requested. Attach additional sheets as necessary.

Section 2: Recruitment Information (Information on the provider/employee for whom you would like to receive funding support)

Training Title:

Training Name/Sponsor:

Location of Training

Training Date/s: To

Number of Staff Participating in Training:

Name, Job Title, and Email of ALL staff participating in training (attach separate form if needed):

Please provide a brief description of the training:

Are there other organizations in the AHI PPS attending or participating?

☐ YES (Identify other organizations) ☐ No/Unsure

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Effective 5.2.16

Identify the DSRIP Project/s this provider/employee supports:

**Specific detail on how this training supports the success of DSRIP implementation in your organization is required for EACH project selected.

Please identify the outcome of the training (certification, new skills, train the trainer, etc.). If a train the trainer program, would this person be available to provide training to other organizations?

Please provide clear documentation on how this training will assist in providing new and expanded services in support of DSRIP projects and goals. What would it mean to have a staff person trained in this area in your organization?

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Effective 5.2.16

Section 3a: Reimbursement for Training Expenses that have already occurred (if training has not yet taken place, please see 3b).

Registration Fee/Vendor Training Fee $

Other Training Costs (if applicable):

Mileage: $ Hotel: $ Meals: $ Supplies: $ Other: $ Other: $

Total Funds Requested: $

Are there in-kind contributions included?

☐ YES ☐ NO

Matching Funds (share %): Equipment: Space for Training: Other:

Were training costs budgeted for or included in organization/department budget? ☐ YES ☐ NO

Please provide copies of receipts/facility documentation with this application to support all expenses. See below for guidance.

Expense Documentation Needed

Training Event - Copy of check request or proof of payment to attend the training event - Copy of contract/agreement with training vendor (if applicable) - If you sponsored the training event, please include a copy of a sign-in sheet

Airfare, Train, Bus, Rental Car, Cab Fare, Parking, Tolls

- Submit all copies of receipts or proof of payment of expenses - Expenses in accordance with reasonable costs shared by

GSA http://www.gsa.gov/portal/content/104877

Hotel - Submit an itemized hotel receipt and/or proof of payment for hotel expenses related to training

Meals

- Submit all copies of receipts or proof of payment of meal expenses with itemized detail

- Write the names of all who had a meal on the receipts - Alcohol cannot be reimbursed by the AHI PPS - Expenses in accordance with reasonable costs shared by

GSA http://www.gsa.gov/portal/content/104877

Mileage - Submit mileage supporting documentation for each employee - Mileage will be reimbursed at the standard IRS rate or the rate set by your

organization, whichever is lower

Supplies - Submit copies of receipts or proof payment for supplies needed for training event (binders, handouts, etc.)

Other - Please identify any “other” expense and include supporting documentation

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Effective 5.2.16

Section 3b: Reimbursement of Expenses for Training to Occur in the Future, with Registration Fees due prior to 9/30/16.

Training/Registration fee paid or due prior to 9/30/16. $

Please provide an estimate of additional expenses to participate in training (mileage, travel, meals, etc.).

$

Please include documentation of registration fees/training fees due prior to 9/30/16 with this request – invoices, conference brochures, etc. Other expenses for training that have not yet occurred may be applied for in the next funding cycle. If your organization is sponsoring the training event, a copy of a sign-in sheet will be required after training has occurred.

Any cancellation fees must be covered by the organization making the request. In addition, if training is cancelled, anymoney received as an advance must be returned to the AHI PPS.

I attest to the best of my knowledge, the above record is a true and accurate account of expenses and adheres to the eligibility criteria outlined in the funding request guidelines.

Submitted by:

Title:

Date:

Return this form and all supporting documentation to DSRIPWorkforce@ahihealth.org. SAMPLE

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REGISTRATION RECEIPT

Care Transitions, Inc. RECEIPT # 1 DATE: MARCH 9, 2016

Care Transitions, Inc. 1234 First Street Indian Lake, NY 12842

REGISTERED Carrie Smith 12345 Main Street Queensbury, NY 12804

PAYMENT METHOD CHECK NO. JOB

Check 0001

QTY ITEM # DESCRIPTION UNIT PRICE DISCOUNT LINE TOTAL

1 Care Coordination Registration $500.00 $500.00

TOTAL DISCOUNT

SUBTOTAL $500.00

SALES TAX N/A

TOTAL $500.00

THANK YOU FOR REGISTERING!

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Queensbury Hospital

Mileage Reimbursement Form

Month: March/April 2016

DATE FROM TO MILES (ONE-WAY) PURPOSE

317/16 Queensbury Hospttal-Pine Health Center Indian Lake Training Center 54 Care Coordination Training

317/16 Indian Lake Training Center Queensbury Hospital-Pine Health Center 54 Care Coordination Training

3/14/16 Queensbury Hospital-Pine Health Center Indian Lake Training Center 54 Care Coordination Training

3/14/16 Indian Lake Training Center Queensbury Hospital-Pine Health Center 54 Care Coordination Training

3/21/16 Queensbury Hospital-Pine Health Center Indian Lake Training Center 54 Care Coordination Training

3/21/16 Indian Lake Training Center Queensbury Hospital-Pine Health Center 54 Care Coordination Training

3/27/16 Queensbury Hospital-Pine Health Center Indian Lake Training Center 54 Care Coordination Training

3/27/16 Indian Lake Training Center Queensbury Hospital-Pine Health Center 54 Care Coordination Training

4/4/16 Queensbury Hospital-Pine Health Center Indian Lake Training Center 54 Care Coordination Training

4/4/16 Indian Lake Training Center Queensbury Hospital-Pine Health Center 54 Care Coordination Training

SIGNATURES:

U/llul k,1'</..-IL- t-J/15/I� Submitted By: Date:

�!/1t/lt; Approved By: CJo/!LlvL /)(µ__ Date:

Additional Approval (if needed): Date:

Expenditures relating to training or travel should be submitted by the employee incurring the expense and require a one level up approval regardless of amount.

{For Finance Only)

Finance Approval

/ ,Jj'} Signature:_-----'{Al(,�

1

-4.<-,d.��-=-----'P:t(=-...;��-----

'--------' Email approval attached Email approval is acceptable if email is attached.

Print Name:_L_tl_f_T-+

1.,/_D.=_tJ....:/....:./_a.._Y-._..::>:__-l

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