Application Form: OHCA Long Term Care Nurse Residency Program

Please complete the below information to apply to participate in OHCA's Long Term Care Nurse Residency Program.

The resident can be a named new hire, or applying facilities can apply for and begin the program with the intention of involving a new hire currently being recruited. We recommend that participating nurse residents are new hires within the past 6 months.

Program Components

The nurse residency program includes the following at no cost to program participants:

Licenses for the Geri-Res Nurse Residency curriculum for both the participating nurse resident and facility-designated mentor (CEUs available)
Optional additional professional development courses for both nurse residents and facility-designated clinical mentor (OHCA’s Nurse Leadership Conference and other OHCA-hosted trainings for nurses)
$500 stipend for the facility-designated clinical mentor (provider discretion, limited availability; this can be used for mentor/mentee team-building activities)
Additional financial support individualized on a case-by-case basis

Question Title

* 1. Applicant Information (this should be a facility administrator or corporate office program point of contact):

Name *

Job Title *

Facility Name *

Organization Type (ALF, RCF, SNF/NF) *

Email *

Phone Number

Question Title

* 2. Residency Requested for (check one):

Nurse to be hired

Identified resident already hired

Question Title

* 3. Program Key Contact Information

Administrator Name (if different from applicant)

Administrator Email (if different from applicant)

Nurse (RN) Resident Name (if identified)

Nurse (RN) Resident Email (if identified)

Nurse (RN) Resident Start Date (if identified)

Mentor Name (if identified)

Mentor Job Title (if identified)

Mentor Email (if identified)

Question Title

* 4. Anticipated Program Start Date

Please enter desired program start date.

Date

Question Title

* 5. Hosting facility agrees to:

Support for the nurse resident, including allowing the nurse resident to compete program educational/curriculum modules (approximately 10 hours) and regular mentoring meetings as a part of their paid time with the organization

Selection and support of facility-designated mentor, including allowing the mentor to complete program educational/curriculum modules (approximately 5 hours) and regular mentoring meetings as a part of their paid time with the organization

Facilitate reporting and feedback with OHCA

Yes, I am able support the nurse resident and mentor according to these requirements.

No, I am not able to support the nurse resident and mentor according to these requirements.