Emergency Workforce Support Fund Application Please read the following information carefully before completing this application. If you have any questions, please reach out to NHF at info@nationalhospicefoundation.org or 703-516-4928. If a disaster has occurred in your area, you may apply for assistance from NHF by filling out the following application form. Once the form is received, it will be reviewed in a timely manner by the NHPCO Emergency Response Team. Please note that if electronic communications are not available, this application can be completed via mail, fax or phone. Only NHPCO members are eligible to apply. Examples of appropriate uses of funds include Distribution of gift cards to staff membersPurchasing and distributing food, water, diapers, hygiene kits, etc. to staff membersFunding transportation, housing and/or childcare for staff membersDirect grants to staff members to assist with the personal loss not covered by insurance If your organization receives funding, you must prepare the Accounting Report and a one-page action report and return it to us within 60 days of the distribution of funds. Therefore, it is important that your organization keep all receipts. If gift cards and/or funds are distributed directly to staff, you must keep detailed records on who received them and what the funds were spent on. Signatures or other form of verification attesting to receipt of funds/gift cards must be obtained. Any funds that were not used for disaster relief and workforce support must be returned to NHF. Failure to submit the Accounting Report will hinder any future requests for assistance. Application Form Hospice Name:* Hospice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Point of Contact name:* Point of Contact Title: Point of Contact Phone*Point of Contact Email* CEO Name:* CEO Email* What was the incident/emergency your organization was impacted by?*Approximate number of staff members affected: ** Amount requested:* *Maximum award is $5,000. No more than $1,000 may be distributed to an individual staff member.Please provide a description of how you intend to use the funds. Please include line items and estimated costs where applicable.*Have you pursued any fundraising or other sources of support to cover these costs (such as community grants, insurance, federal or state emergency funding)? What was the outcome of those attempts?*Please provide your average daily census as of January 1* What is the level of support that has been provided by your state and/or has it been requested?*Is there any other feedback or information you would like to share? I certify we are requesting funds for incurred costs related to an emergency which cannot be covered by insurance, state or federal emergency funding, or community funding. I acknowledge that any funds received from the National Hospice Foundation’s Emergency Workforce Support Fund are only to be used for the costs indicated in this application that are approved by the NHF staff. I agree to submit receipts for any costs paid using this grant as well as a one-page impact report to the National Hospice Foundation within 60 days of using the funds. Any amount of the grant that is not or cannot be used for approved costs must be returned to NHF. I understand that if I do not comply with the financial reporting requirements that my organization may not receive grants in the future. Representative Signature (your initials);* Date* MM slash DD slash YYYY Untitled
