Infection Prevention Training Reimbursement Opportunity Form

Name: Colorado Health Care Association
Address: 4100 E. Mississippi Ave. Suite 925, Glendale, CO, 80246
Telephone: 303-861-8228

Name of Applicant
First Last
Email*
Phone*
Nursing Facility Name
Date of Application
MM slash DD slash YYYY
Upload Signed NHA Letter of Support*
I agree my NHA has completed the letter of support
I hereby agree that my NHA for my Facility is aware of the application for the IPCO Grant through CHCA and the signed letter of support will be attached to this form.
Upload NHA Letter of Support*
Accepted file types: doc, pdf, Max. file size: 21 MB.
Please Note that the NHA letter of support must be in PDF form.

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