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Appendix E Please Download this Form in one of the following formats: Department of Health and Human Services’ Office of Adult Mental Health Services
and The Center for
Learning
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1) |
My position is funded by a DHHS contract ………………………….….…. |
Yes
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___ |
No |
___ |
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2) |
My position is DHHS funded for 20 hours (half-time) or more..……….…… |
Yes
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___ |
No |
___ |
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3) |
The applicant has a Provisional MHRT/Community Level B Certification on file with the Center for Learning …………………………………………...… |
Yes |
___ |
No |
___ |
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4) |
The course(s) identified are required for applicant’s present position and for MHRT/Community Certification…………..………………………..….... |
Yes |
___ |
No |
___ |
C. - COURSE IDENTIFICATION: (Please enter cost of tuition for the class: $__________ )
School,
Campus & Location:
(Note: Please list the
name of the institution you will be attending in the above information)
Course Title:
(Note: A separate request sheet
must be made out for each course.)
Reimbursement to: (Circle One) SELF
AGENCY Undergraduate Graduate
Course
____ Course ____
D. - SEMESTER: Please list the Semester/Year of the course here:
E. - APPROVAL:
Supervisor’s Name:
_____________________________ Date:
(Please Print Clearly)
(Supervisor Signature)* (Applicant Signature)
*NOTE:
Supervisor’s signature indicates that all Eligibility Statements are accurate
and that individual is authorized
to submit this request.
BOTH STUDENT & SUPERVISOR SIGNATURES ARE REQUIRED
Completed form must be returned to: The Center For Learning, 45 Commerce Dr. Suite 11, Augusta, ME 04330 Attn: Tuition Reimbursement or faxed to 626-5022. The DHHS Office of Adult Mental Health Services will reimburse only the actual tuition costs for the course (up to a maximum tuition rate for an undergraduate 3 credit course at USM). Students understand they are responsible for books and fees. Reimbursement will be made after receipt of an official transcript for the course with a grade of "C" or better. Students must submit the transcript directly to the Center For Learning for reimbursement. Grades must be mailed within 30 days of close of class. There is a limit of three classes per fiscal year (July 1 through June 30).
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