2014 OFNHP RN Education or Certification Fund Reimbursement Expense Form REQUESTS FOR REIMBURSEMENT: Please see attached OFNHP RN Education and Certification Reimbursement Fund policy for reimbursement guidelines. Proof of payment and grades/course completion required. Employee Name: Employee ID #: Tie-Line: Date: Position: Facility: Department: Home/Cell Phone: Explanation of Reimbursement Requested Fund Date Ed Cert Start/End Amount 1. 2. 3. 4. 5. Total Reimbursement Amount Requested: I understand reimbursement(s) are subject to the provisions on the OFNHP RN Education and Certification Fund policy to which I am applying. I have read the instructions on the following pages for clarification before submitting this request. I certify that these expenses are true and correct to the best of my knowledge. X Employee Signature Date HR USE ONLY Date of Hire: Active EE EE Group/Entity: Yes No Human Resources Signature: TR Exhausted? Yes No TR Eligible? Yes No TR Amount Paid: TR Amount Unpaid: Coded Hours: Approved Denied (see attached) Pay Period/Date: Union Amt Paid: Pay Period/Date: Amount Unpaid: Overage Paid: Overage Unpaid: Pay Period/Date: Approved Amount Approved: COMMITTEE USE ONLY (If Applicable) Denied Reason for Denial: Education Committee Rep. Signature: For End Of The Year Overage Amount Approved: Education Committee Rep. Signature (for Overage Approval): Send Application to: Tuition Reimbursement / HR / KPB-13 _ Date: _ Date: Revised 12.2.13 Page 1 of 5
Instructions for Completing and Submitting the OFNHP RN Education Fund or Certification Fund Reimbursement Form: 1. The KPNW Tuition Reimbursement Fund, OFNHP RN Education Reimbursement Fund, and OFNHP Certification Reimbursement Fund are three separate funds. Reimbursements paid out of each fund are processed independently. 2. The OFNHP RN Education Committee no longer processes the RN Education and Certification Reimbursement Fund requests. Requests are processed by the Human Resources department. Please refer to page 4 for information about how to contact committee members with any questions. 3. Fill out the form completely. Check the corresponding Ed/Cert column to indicate which fund you are requesting reimbursement from (OFNHP RN Education or Certification Reimbursement Fund). Submit requests to the KPNW Tuition Reimbursement Fund on the 2014 KPNW Tuition Reimbursement form. Use Explanation of Expense field to list course, seminar, books, or other education expenses. 4. Please send completed form along with proof of payment and proof of completion to Tuition Reimbursement, Human Resources, KPB-13. Reimbursement will be added to your payroll check as non-taxable income. 5. For further information, go to the My HR Portal online. Under the KP & Me tab, select the Career Development link, and then the Education Assistance link. You will find the current information and forms for the education programs available to you as a KP employee. 6. Please note that the OFNHP RN Education and Certification Reimbursement Funds are reimbursement funds. The funds do not prepay education expenses. Revised 12.2.13 Page 2 of 5
OFNHP RN Education Fund or Certification Fund Reimbursement Policy Eligibility All current KP OFNHP RN Union members with six (6) months of continuous service in any status (regular, short hour, or on-call) are eligible. Guidelines 1. Eligible Programs: Educational programs relevant to the needs of the employee and to the health care needs of Kaiser Permanente patients (i.e. continuing education, professional development, education and/or licensure, and personal development.) 2. Eligible Expenses for the OFNHP RN Education Reimbursement Fund: Registration fees for seminars, workshops and conferences, and online classes for CEU credit. May also include tuition reimbursement in excess of funds provided under the KPNW Tuition Reimbursement Policy. 3. Eligible Expenses for the OFNHP RN Certification Reimbursement Fund: Fees for classes, books, CD s, or other study related materials to assist in obtaining RN specialty certifications. Fees for certification exams, up to two (2) tries per specialty exam. Fees for re-certifications/certification maintenance. Covers national certifications such as CCRN, CNOR, CEN, etc. Does not cover Oregon or Washington state RN license. Any certification that is required to maintain employment will be paid for by the employee's department (Please contact your manager). 4. Ineligible Expenses for the OFNHP RN Education and Certification Reimbursement Funds: Meals, hotel incidentals, telephone calls, rental cars, wages (reimbursement for time loss), child care, parking fees, auto fuel, mileage, lodging, sitting for license boards, injured workers training as covered by Workers Compensation or outside insurance, professional dues and subscriptions, annual license fees or dues, retraining as part of RIFs. 5. OFNHP RN Education Reimbursement Fund Yearly Allowance: maximum of 200.00 per employee, per year until the OFNHP RN Education Fund of 44,660 is exhausted. 6. To request reimbursement, please provide the following information: Proof of Payment: copy of receipt or copy of cancelled check (front & back) or copy of bank or credit card statement (black out your account #) or copy of e-confirmation of payment Revised 12.2.13 Page 3 of 5
AND Proof of Attendance: A copy of Certificate of Completion showing CME or CEU credits or copy of Certificate of Attendance or copy of National Certification IMPORTANT: The processing of your reimbursement will be delayed if any of the above information is missing or your documentation is incomplete. 7. You may obtain a 2014 OFNHP RN Education Reimbursement Form online via the My HR Portal, from your OFNHP RN Education committee representative, online at http://ofnhp.org/, or by sending an email request to Tuition Reimbursement at NW-HRServices@kp.org. 8. Requests are reviewed by Human Resources. If you have an appeal, the application will be forwarded to your OFNHP RN Education Fund committee representative for review. 9. After you submit your request, review your pay statement to confirm reimbursement. Note: funds may not appear on your payroll statement for up to two (2) pay periods following a complete submission. Appeals Send your written appeal to your committee representative who will bring the appeal to the OFNHP RN Education Committee. OFNHP RN Education Committee Representatives Margaret McGowan-Tuttle: margaret.mcgowan-tuttle@kp.org Rae Lunde: rae.a.lunde@kp.org Deborah Buchwach: deborah.buchwach@kp.org Revised 12.2.13 Page 4 of 5
KPNW Tuition Reimbursement Policy Eligibility Regular employees coded 20 hours or more per week, and who have been employed with Kaiser Permanente on a continuous basis for one year for more are eligible for Tuition Expense Reimbursement. Temporary and on-call personnel are not eligible for the program. Guidelines 1. The course or training must be taken from an accredited school, junior college, university, or other equivalent institution that has been accredited by the Western Association of Schools and Colleges. University extension correspondence and online courses are considered equal to any other college course. 2. Consideration may be given to non-accredited educational programs which are approved by a recognized management or professional organization. Please email NW-HRServices@kp.org or call the Education Coordinator at 49-4005 to confirm if the course you wish to take meets requirements for approval. 3. Reimbursement is offered up to 600 per year. Please see below for eligible/ineligible expenses. 4. The courses or training may or may not carry credits. CME and CEU accredited courses are eligible. 5. There is no restriction on the number of courses eligible for reimbursement per school term. 6. Reimbursement will not be approved if other financial assistance (e.g., scholarships, GI Bill) is received for the course, degree, or certificate program. 7. Employees who take an unpaid leave of absence for the purpose of education, at any time during the course, degree, or certificate program, are not eligible. The eligibility of employees, who take a medical, military, parental or family leave any time during the course of study, shall be subject to review by the Education Coordinator. 8. Kaiser Permanente will not reimburse educational expenses if an employee resigns or is terminated prior to completion of the course, degree, or certificate program. Eligible Expenses for KPNW Tuition Reimbursement Fund Expenses which are covered include: Seminars, workshops, conferences, and educational meetings. Course tuition, required entrance/registration fees, required textbooks and laboratory fees. Ineligible Expenses for KPNW Tuition Reimbursement Fund Expenses which are not covered include, but are not limited to: Hotel accommodations and meals while attending conferences/meetings. Parking, mileage, transportation to and from place of instruction. Cost of periodicals, reference books, supplies, uniforms and equipment. Computer software. Professional association registration (fundsmaybe available through department budgets or union sponsored programs such asofnhp Professional Unit Education Fund). Courses and training related to: recreational activities, music, art, dance, religion, physical fitness,drama,hobbies, etc. Revised 12.2.13 Page 5 of 5