Summer Health Care Intern Program (SHCIP)
2010 Employer Application
Submit all sections by April 19, 2010 to establish a grant
agreement for participation in this program.
**Only one application per organization is allowed. If you are submitting for more than one organization, please refresh (press F5) the form between submissions; otherwise a database error will occur.
Please proof-read for accuracy and do not use ALL CAPS. Mailings and grant materials are prepared directly from your typed input.

I. Organization Information

  
Date:
Organization Name: Hospital               Clinic
Home Health Agency/Assisted Living Residence
Nursing Facility   
Street Address:
City: State: Zip:
MN Tx ID No. Federal Employer Tax No.
Administrator or business manager
(Person who will sign grant agreement)

First Name: Last Name:

Organization contact person for SHCIP
(Person who will be implementing program)

First Name: Last Name:

Phone#    
Fax# Email

II. Requested SHCIP estimated cost and reimbursement

$            X
(Average internship hourly wage)*
(put only numbers/decimal in this field) 		           X
(Average total number of hours per student)**
Minimum 100 hours
Maximum 480 hours
(put only numbers in this field) 		         =
(Total number of students)
(put only numbers in this field) 		            / 2
(estimated total cost of employment for summer)
(this is a calculated field, it cannot be edited)
(Approximate amount of reimbursement requested)
(this is a calculated field, it cannot be edited)
SHCIP Reimbursement Formula Process (please read)

III. Employment Plan
Areas of employment: (250 character max)
characters left
Duties Expected: (250 character max)
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Scheduled
orientation time (numbers only) 		Scheduled
observation time (numbers only)
The program recommends 10 to 20 percent of the intern's time be scheduled for only observation and/or job shadowing to help them experience several health care careers 		Work hours
per week (numbers only)
Areas to be observed:
(Tailored to individual student interest:)
(250 character max)
characters left

I have read and agree to the SHCIP reimbursement process above

An e-mail confirming the submission will be sent to the organization contact person for SHCIP. Please retain the e-mail for your records. If you do not receive a confirmation e-mail, please contact Sarah Bohnet

Funding for this program is provided through a contract
with the Office of Rural Health & Primary Care, Minnesota Department of Health.