Nursing Home Profile Form for the Reading2Connect CMP Grant Application
This form provides Reading2Connect (R2C) with the information it needs to complete a Reading2Connect CMP application for your Nursing Home (NH). Note: The nursing home administrator is the official applicant. The contact person is usually the Activity Professional who becomes the "Reading2Connect Certified Coach."
Name of Certified Nursing Home
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Nursing Home Website
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Administrator's Name
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First Name
Last Name
Administrator's Title
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Position
Administrator's Email
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example@example.com
Contact Person's Name
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First Name
Last Name
Contact Person's Title
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Position
Contact Person's Email
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example@example.com
Nursing Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nursing Home Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Nursing Home (NH) Shipping Address to Receive R2C Materials
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CMS Certified Number
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Check each statement below if true. For a NH to be eligible for Reading2Connect's free service of completing the NH CMP Grant application, all statements below must be checked.
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I affirm that the above mentioned nursing home (NH) is not participating in another CMP-approved project.
I affirm that this NH does not have any outstanding CMP fines.
I affirm that this NH is not in bankruptcy or receivership.
I acknowledge that this Reading2Connect CMP Project is for one year from the date that the CMP Grant Application is approved by CMS.
I acknowledge that Reading2Connect (R2C) will complete the CMP Grant Application on behalf of this NH.
I acknowledge that R2C will send the completed CMP Grant Application to the applicant named above within 30 business days of receiving this Nursing Home Profile Form.
I acknowledge that the NH administrator will be responsible for submitting the CMP Grant Application to the relevant state agency, and that this NH will be the grantee. (CMS requires that all NH CMP applications be submitted by the NH administrator or a corporate employee.)
I acknowledge that, as grantee, this NH is responsible for all project reporting to the state agency, as required by the state agency.
I affirm that I am authorized to commit the above-named NH to this proposed Reading2Connect CMP Grant Project.
Approximately what percentage of residents in your nursing home have been diagnosed with Alzheimer's or a related disease that includes symptoms of dementia?
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Please provide the background and history of this NH. Include the NH’s number of years in service and its mission statement. (2-3 paragraphs)
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Please provide information about this NH's capabilities, including how you intend to use the Reading2Connect resources relevant to the services you provide. You want to show that you have the resources and support necessary to successfully implement and sustain the Reading2Connect Program. Include the name and position of the main person (ie, R2C Coach) who will be implementing the Reading2Connect Program. (2-3 paragraphs)
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Please share any additional information about your community that would be impactful. (1-2paragraphs)
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Is this NH planning to contribute funds to this CMP Project? Has this NH applied for other funding for this project? Has this NH received other funding for this project?
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No, to all three questions above.
Yes, to one or more of the three questions above.
If "yes" to one or more questions above, please explain here.
I understand the project roles, responsibilities, and estimated timeline outlined on this form. I authorize Reading2Connect to begin developing the CMP Grant Application for the above named nursing home.
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Yes
No
Signatory's name and title
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Date of signature
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Signature
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