KIRKWOOD MERIT SYSTEM

The purpose oftheKirkwoodMeritSystemistoencouragechaptermember participation in chapter events. Pointsare earnedfor different chapter and professional activities. Pointscan then be usedtoward reimbursement of expensesfor such things as nursingeducation,NTI, orfor other professionalnursingeducational materials/activities(providedtheapplicantsuppliesthechapter withpaidreceipts).

I. General Information

A.Allfundsawardedfromthechapterareawardedonlytochaptermembersand are non-transferrablebetweenchaptermembers or fiscal years. The applicantmusthavebeen aNational andLocal member for1 year, prior toreceivingfunds.

Note: SCCC members from September 1, 2014 to June 30, 2015 can participate

B.Theapplicantmustapplywith a completed points worksheet, a list of educational programs,booksorjournals that have already been purchased, and a copy of all receipts (See Reimbursement Request sheet). Programs,booksor journalsshallbe content-related tothe developmentof expertise in critical carenursing.

C.Thenames ofthe reimbursementrecipients will be announced/displayed by thechapter.

II. Guidelines

A. Points maybe accrued for1 fiscal yearonly.

1. There is a limited amount of funds available each year. Maximum points accruable peryear will be determined by chapter BOD, and included in our chapter’s annual budget.

NOTE: For FY 2015-2016: The chapter BOD has determined a max of 25 points.

2. Points mustberedeemedduringthefiscalyear in which they are accumulated.

3. A fiscalyear is July1 through June30.

B.Pointsmust be submitted once and usedintotal. A Reimbursement Request form mustbesubmitted with receipts or proof of attendance.

C. PointsmayNOTbeusedtopaymembershipduestoeitherlocalornational

AACN, or anyother professional association.

III. PointRedemption

A. Pointswillberedeemableat$10perpointwiththemaximumredeemablevalue of $250for 25points. Reimbursement will occur as a onetime lump sum. If Points/Money remaining after reimbursement, they will be not carry over to the next fiscal year.

B.Applications for reimbursement must be submitted one month prior to the appropriation of monies. Reimbursement requestsshouldbesubmittedtothe Chapter President-Elect, with supportive documentation for review by the chapter BOD, no later than June 1, 2016 for the current fiscal year (July 1, 2015 – June 30, 2016).If items are denied reimbursement, the President- Elect will notify the member.

IV. Reimbursement Request Submission Options (Select one no later than June 1, 2016):

  1. In person to any chapter board member, or
  2. By Postal Mail: Erin Hallinan, 10 Red Rock Road, Branford, CT 06405, or
  1. Email with scanned supporting documents attached:

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KirkwoodMerit Scholarship: Request for Reimbursement FY 2015-2016

Directions: Complete the Point Worksheet, with total points for the fiscal year (July 1, 2015- June 30, 2016) . Maximum number of points is 25. List receipt items and submit copies of receipt or proof of attendance/initials/names as noted on Worksheet along with this form. Submit to chapter President-Elect no later than June 1, 2016.

Must be a chapter member 9/1/2014 - 6/30/2015 to participate in Kirkwood for 2015-2016

Name

DateofApplication

Address

Best Phone Number to reach you:

AACNMemberNumber EXP. Date

In the space below, list items (educational program, bookorjournal conference etc) that you are submitting receipts or proof of attendance for. Total amount of receipts: $_

Applicationfor Kirkwood reimbursementmust be submitted to Chapter President-Electalong withthework sheet and verificationmaterials/paid receipts no later than June 1, 2016. Submit in person, mail to Erin Hallinan, 10 Red Rock Road, Branford, CT 06405, or email (scan documents including receipts). Checks will be mailed within approximately 1 month of request, pending chapter board approval.If items are denied reimbursement, the President- Elect will notify the member.

Note: You can only be reimbursed for the amount of your receipts. You may have unused points that cannot be redeemed or accrue. Points only apply 7/1/15 -6/1/16.

Member’s Signature

BoardofDirector’s UseOnly

MemberFY 7/2015 – 6/2016

Total NumberofPoints from worksheet ____ equals max of $($10.00/point)

Date AmountPaid Check Number______

DateApproved

Date to Treasurer

Treasurer’s SignaturePresident-Elect’s Signature

KirkwoodMerit System Point Worksheet

FY7/15 to 6/16

Name ______

Activity / Points
A. SCCCMembership current year only / (2)
B. Attendance atMonthly Board Meeting(Max 10, requires Initials) / (2)
C. Recruitmentofnew chapter members (maximum5) / (2)

Only one member can claim each recruit named below:

1.

2.

3.

4.

5.

Certifications: Max of 2 total D & E.

D. Any AACN Certification(eg. CCRN, PCCN attach copyofcard)(5) E. Non AACN professional certification(ANCC, Palliative, etc ) (3)

F. Membership in anotherprofessionalnursingorganization (Max 2)(1)

Name(s)(attachcopyofcard)

1.

2.

G. Attendance atworkshop,seminar, or chapter CE program(1 per1 contacthour) (Maximum10 points)

H. Otherorganized AACN SCCC chapter activities(4)

(Evidencerequired orinitials ofchairperson)

I. Activememberon a BOD committee(5)

Committee

Chairperson’s initials

J.ChapterHospitalRepresentative(2)

K. Nominate and present Chapter Nurse Hero Award(2)

L. ChapterOfficer

1. President(10)

2. President-elect(10)

3. Secretary(10)

4. Membership(10)

5. Treasurer(10)

6. Treasurer-elect(10)

7. Nominating (10) _____

8. Horizons Rep(10) ______

9. On Ballot for BOD position Spring 2016(10)

M. Guestspeakerforan AACN/SCCC chapter program(5 perhour)

(attach evidence)

N. Publication(attachcopy)

1 Article in nursingpublication/textbook(5)

O. Research(attach copyofabstract/evidence)

1. Primaryresearcher (PI)orco-investigator (8)

2. Oral/Poster Presentation (4)

3. Activelyinvolved in research project (requires proof from PI)(4) P. MemberofNationalBoard ofDirectors (10)

Q. MemberofNationalCommitteeortaskforce(5)

Committee

Totalpoints

Pointconversion=$10equivalentperpoint. CAP for 2016: 25 points Eligibleamount$

Submit on or before June 1, 2016