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Training and Education Fund Application

Please complete the following application when requesting funds to support training/education initiatives.

You will be asked to supply supporting information including receipts for past expenses or documentation of anticipated expenses for future events/activities.

If you have any questions, please email training@abhealth.us

1. Organization information *This question is required.

Organization Name:
Address:
Contact Person:
Title:
Email address:
Phone:

2. Training/Education Information *This question is required.

Training/Education Title:
Training/Education Name/Sponsor:
Location of Training/Education:

3. Please attach a document including the name, job title, and email of ALL staff participating in training/education:

File: {{filename}} delete

4. Please provide a brief description of the training/education: *This question is required.

5. Are there other organizations in the Alliance for Better Health PPS attending or participating? *This question is required.

Please enter an 'other' value for this selection.

6. Please clearly explain how this training/education will assist in providing new and expanded services in support of DSRIP performance measures, projects and goals. What would it mean to have a staff person trained in this area in your organization? *This question is required.

7. Please provide copies of receipts/facility documentation as appropriate to support all qualifying expenses including travel, supplies, accommodations, etc. Please see Training and Education Fund Guidelines for additional guidance.

File: {{filename}} delete

8. Please identify the outcome of the training (certification, new skills, train the trainer, etc.) and showcase sustainability. If a train the trainer program, would this person be available to provide training to other organizations? *This question is required.

9. DSRIP Projects and Performance Measures: DSRIP Projects

Please select all DSRIP projects this training will support. *This question is required.

10. DSRIP Projects and Performance Measures: Claims Based Measures

Please select all DOH performance measures this training will support. *This question is required.

11. DSRIP Projects and Performance Measures: Non-Claims Based Measures

Please select all DOH performance measures this training will support. *This question is required.

Palliative care IPOS
Survey - always/usually timely access
Survey - care transitions
Survey - care coordination
PAM Score
% Medicaid patients with no primary care visit
% Uninsured patients with emergency dept visits
Survey - usual source of primary care
Survey - 1+ year provider relationship

12. Reimbursement of expenses for training

Indicate how much you are requesting for training/registration fees as well as additional expenses (for example travel).

In the next field, please include documentation of registration/training fees with this request - invoices, conference brochures, etc.
*This question is required.

Training/Registration fee(s)
Please provide an estimate of additional expenses to participate in training (mileage, travel, meals, etc.)

13. I attest to the best of my knowledge; the above record is a true and accurate account of information and expenses, and adheres to the eligibility criteria outlined in the Training and Education Fund Guidelines. *This question is required.

Submitted by:
Title:
Date: