Excellence in Employment Practices Fund Reimbursement Form 2018 The Excellence in Employment Practices fund (the Fund) has been allocated to a proactive risk management initiative in 2018. The goal is to PREVENT ONE employment practices liability claim for California Healthcare Insurance company, Inc., RRG (CHI) owners who purchase the optional EPL coverage on their CHI policy. PREVENT ONE will provide expense reimbursement for approved risk mitigation efforts, up to $3000 per CHI owner (with EPL coverage). Reimbursement is for efforts/services incurred in 2018 and must be submitted by December 14, 2018. To obtain PREVENT ONE program reimbursement, complete this form and attach a copy of the facility's check and invoice supporting the EPL expense(s). Maximum reimbursement amount not to exceed $3000. Facility*Barton HealthcareBeverly HospitalCarson Valley Medical CenterCitrus Valley Faculty PartnersCitrus Valley Health PartnersCitrus Valley Physician PartnersCollege HealthCollege Hospital CerritosCollege Hospital Costa MesaCollege Medical CenterDameron Hospital AssociationEastern Plumas Health CareEnloe Medical CenterEskatonGlenn Medical CenterHealdsburg District Hospital (North Sonoma)Henry Mayo Newhall HospitalMadera Community HospitalMontage HealthNorthBay Healthcare CorporationOrchard HospitalOroville HospitalPacific Alliance Medical CenterPomona Valley Hospital Medical CenterRideout HealthSan Antonio Regional HospitalSouthern Humboldt Community Healthcare DistrictTahoe Carson Valley Medical GroupVista Cove Senior LivingName* First Last Title/Position*Phone*Email* 2018 Expense Reimbursement Description*Legal Expense - Difficult employment practices situationLegal Expense - Review/revision of Employee HanbookLegal Expense - Review/update of Human Resources (HR) policies and proceduresLegal Expense - Consultation fees prior to leave of absence (LOA) or separation of employmentMembership fee to Society for Human Resources Management (SHRM)Membership fee to American Society for Healthcare Human Resources Administration (ASHHRA)Software expenses to invest/implement/update HR information management softwareRegistration fee for HR employees to attend annual CHA Labor & Employment Law seminar (Fall 2018)Certification expenses for HR staff to become certified as Senior Professionals in HR (SPHR)Consultant or legal expenses related to developing formal HR-related training program for managementConsultant or legal expenses related to establishing centralized Absence Management Process with specific written procedures for the accommodation process, including specific time frames, documentation and tracking requests for reasonable accommodation, while ensuring the confidentiality of the employee's medical informationConsultant or legal expenses related to the performance of an HR risk assessmentConsultant or legal expenses for audits on HR policies or records such as time and attendance and staff competencyIf " other" is chosen, please consult your Optima risk management consultant for reimbursement approval. Reimbursement Request Amount*I verify these funds were used in 2018 for EPL risk mitigation purposes.*YesInvoice* Drop files here or Please upload a copy of the invoice for which reimbursement is being requested. Check/Transaction Copy* Drop files here or Please upload a copy of your facility's check or confirmation of financial transaction confirming payment of the above services.