WisCaregiver CNA Program Employer Registration Form

Page 1

Application Type

Nursing Home Name

Nursing Home Address Line 1

Nursing Home Address Line 2

Nursing Home City

State

Postal Code

Primary Contact Information

CNA training/Supervisor Contact First Name

CNA training/Supervisor Contact Last Name

CNA training/Supervisor Contact Title

CNA training/Supervisor Contact Phone Number

CNA training/Supervisor Contact Email Address

Additional Contact Information

Accounts Receivable Contact Person (first and last name)

Accounts Receivable Contact Person Title

Accounts Receivable Contact Person Phone Number

Accounts Receivable Contact E-mail Address

Recruiting/HR Contact First Name

Recruiting/HR Contact Last Name

Recruiting/HR Contact Title

Recruiting/HR Contact Phone Number

Recruiting/HR Contact E-mail Address

Do you know who your facility's TMU contact is?

YesNo

TMU Contact First Name

TMU Contact Last Name

TMU Contact Title

TMU Contact Phone

TMU Contact Email

Postal Code

What type of entity/provider are you?

Skilled Nursing Facility Other

If you selected other - please provide us with what type of entity/provider your facility is

Please enter the main webpage/home page URL for your facility

URL Web Address for CNA TRAINEE Job Posting

Employer Registration Acknowledgment As a skilled nursing facility participating in the WisCaregiver Careers CNA Program, you are required to review and agree to the following:

ForwardHealth Reimbursement Requirement Effective 1/1/2026, all reimbursement requests for CNA training and testing must be submitted through ForwardHealth using Form F-01013. WisCaregiver Careers does not process or track reimbursement for training and testing. Questions related to submissions, invoices, or reimbursement tracking for training and testing must be directed to the facility’s ForwardHealth representative.

We agree

Training and Testing Costs All reimbursements for CNA training and testing will be issued directly to your facility and not to the individual. The handling of CNA training and testing costs is determined by the facility. Any related expectations must be clearly communicated to the participant prior to the start of training.

We agree

Participant Eligibility The WisCaregiver Careers CNA program is only available to individuals seeking first-time CNA certification. Individuals who are previously certified, expired, lapsed, or seeking recertification are not eligible to participate.

We agree

Employment and Retention Bonus Your facility agrees to hire participants into entry-level roles and coordinate CNA training. Eligibility for the $500 retention bonus requires that the facility has funded the individual’s training and that the participant remains employed for 6 months following certification. Upon meeting these requirements, the $500 retention bonus must be issued to the employee by the facility prior to reimbursement. Reimbursement is contingent upon accurate setup of the participant’s TMU account in accordance with the requirements outlined in the Employer’s Guide.

We agree

Employment and Retention Bonus Your facility agrees to hire participants into entry-level roles and coordinate CNA training. Eligibility for the $500 retention bonus requires that the facility has funded the individual’s training and that the participant remains employed for 6 months following certification. Upon meeting these requirements, the $500 retention bonus must be issued to the employee by the facility prior to reimbursement. Reimbursement is contingent upon accurate setup of the participant’s TMU account in accordance with the requirements outlined in the Employer’s Guide.

We agree

Employer Guide Acknowledgment and Responsibility Your facility is responsible for reviewing and following the most current WisCaregiver Careers Employer’s Guide, which outlines program requirements, timelines, TMU setup expectations, and retention eligibility criteria. Failure to follow these requirements may impact eligibility of reimbursements.

We agree