DHS-6818-ENG 10-20 (1.1.0)

Emergency Staffing Pool Request

Required field

Background

The State of Minnesota offers certain providers of residential services the option of requesting short-term emergency temporary staffing if they are experiencing an unexpected staffing shortage due to an actual or suspected infection COVID-19 at their facility. If deemed eligible, your organization will receive temporary replacement staff for a period of up to 14 days from a third-party staffing agency selected by the State of Minnesota at no cost to the provider. There may be additional limits and restrictions on the use and type of staff available during the pandemic. While the State of Minnesota will make every reasonable effort to meet providers' appropriate requests for temporary replacement staffing, the provider retains responsibility for all requirements of their license and continuity of services for their residents.

Instructions

Please complete all the required information. The last section provides information regarding the standard terms and conditions that will govern staffing agency contracts that result from this request. This form must be signed by the administrator or person having authority to bind the applicant organization.

Note: If you have an electronic copy of your facility's crisis staffing plan available, please have it ready before starting the application. Upload the plan before submitting the application approval.

DHS is still working with the staffing vendor access to the background studies for DHS licensed program. This may result in a delay for staffing for those facilities.

Suspected or confirmed COVID cases of staff or residents at facility?

Yes

Your facility is denied temporary staffing since there are no suspected or active COVID outbreaks. Please tell us about your COVID needs by completing the Provider Alert Survey. If your needs change, please complete a new application request.

Official program contact

FIRST NAME

LAST NAME

TITLE

PHONE NUMBER

ORGANIZATION NAME

TYPE OF FACILITY

FACILITY ADDRESS

CITY

ZIP CODE

COUNTY/TRIBE

LICENSE NUMBER (if applicable)

ID numbers

REGISTERED 501(C)(3)

Yes

NUMBERS

Business or accounting manager contact

Is the business or accounting manager different than program official?

Yes

FIRST NAME

LAST NAME

TITLE

PHONE NUMBER

ORGANIZATION NAME

FACILITY ADDRESS

CITY

ZIP CODE

Crisis staffing plan

Only PDF or Word files may be uploaded.

Upload crisis staffing plan

Terms and conditions

By submitting this application electronically, I certify that I have read all application documents and agree to comply with their requirements and all applicable federal, state, and local laws, ordinances, rules, regulations, and policies, if selected and that I have authority to submit on behalf of my organization.

The facility verifies that it is making this request due to a critical lack of staff available to provide services due to a COVID-19 outbreak. Despite best efforts, the facility has not been able to find replacement staff, and is not eligible for reimbursement for emergency staffing through other government programs. The facility agrees that the State is not the employer and that the State does not warrant the suitability of any given staff that may ultimately be working in the facility.

Person with authority to sign

FIRST NAME

LAST NAME

ELECTRONIC SIGNATURE (type name)

TITLE

Review

ID OF PERSON REVIEWING

COMMENTS (Include priority, number and types of staff approved)

BUSINESS AREA ASSIGNED

APPLICATION STATUS

DENIAL REASON

DESCRIBE OTHER DENIAL REASON

VENDOR STATUS

RN

NUMBER OF RNs WORKED

HOURS WORKED

COSTS

LPN

NUMBER OF LPNs WORKED

HOURS WORKED

COSTS

DCS with certification

NUMBER OF DCSs WORKED

HOURS WORKED

COSTS

DCS without certification

NUMBER OF DCSs WORKED

HOURS WORKED

COSTS

Form State Cd

Emergency Staffing Pool Request

Background

Instructions

Suspected or confirmed COVID cases of staff or residents at facility?

Official program contact

ID numbers

Business or accounting manager contact

Describe the situation that requires emergency staffing at time of application

Crisis staffing plan

Terms and conditions

Person with authority to sign

Review

RN

LPN

DCS with certification

DCS without certification