Fillable UW S ystem Student Health Care Worker Program (University of Wisconsin - Green Bay)

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UW S ystem Student Health Care Worker Program (University of Wisconsin - Green Bay)

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The UW S ystem Student Health Care Worker Program (University of Wisconsin - Green Bay) form is 1 page long and contains:

  • 1 signature
  • 6 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

U.S.A. forms for University of Wisconsin - Green Bay

BROWSE UNIVERSITY OF WISCONSIN - GREEN BAY FORMS

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Please know that
has worked at least
50 hours at this facility between
the dates of December 1, 2020 and January 31, 2021 working in the role checked below:
☐RN ☐LPN ☐CMA
☐CNA
☐CEMT
This work should qualify the student for the UW System’s tuition credit as announced in December of 2020.
If you have any questions, please contact Jeff Buhrandt, UW System’s Associate Vice-President of Government
Relations at (608) 262-1312, or jbuhrandt@uwsa.edu
.
___________________________________________ ______________________________________
Signature of Healthcare Facility Representative Date
__________________________________________ ______________________________________
Printed Name of Healthcare Facility Representative Title/Position
__________________________________________ ______________________________________
Email address Phone Number
TO BE COMPLETED BY THE STUDENT:
___________________________________________ ______________________________________
Student Name Student ID Number
STUDENT: Please submit completed form to the Bursar on your UW campus no later than March 31, 2021.
☐Nursing/Resident Assistant/Nurse Extern/CBRF
DATE:
TO:
FROM:
RE:
UW S
ystem Student Health Care Worker Program
NAME OF HEALTH CARE FACILITY:
ADDRESS:
CITY: STATE: ZIP
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UW S ystem Student Health Care Worker Program (University of Wisconsin - Green Bay)

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Completed 2 February 2021

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