• IMPORTANT APPLICATION INFORMATION •Applications must be faxed, e-mailed or postmarked within 90 days of the completion date of the professional development activity or by March 31, 2016, whichever date comes first. Late and/or incomplete applications will be declined. Funding is not guaranteed.

• OnlyprofessionaldevelopmentactivitiescompletedbetweenApril 1, 2015 and March 31, 2016are eligible for grant funding.

• Applicantsarerequiredtosubmitonlyone(1)courseperapplication.

• Themaximumamountoffundingforeacheligiblehealthprofessionalis$1,500perfundingyear.

• Applicationswillbeprocessedintheorderinwhichtheyarereceived.

• Applicationswillbeevaluatedinaccordancewiththeobjectivesofthefund(pleaseseeabove).

• Preferencewillbegiventoapplicantscurrentlyemployedandprovidingcareandapplicantswhodidnotreceive$1,500inthepreviousfiscalyear.

HealthForceOntario’sAlliedHealthProfessionalDevelopmentFund(AHPDF)makeseducationalopportunitiesavailabletoalliedhealthprofessionals.Theinvestmentsupportsprofessionaldevelopment(PD)opportunitiesforAudiologists,Dietitians,MedicalLaboratoryTechnologists,MedicalRadiationTechnologists,OccupationalTherapists,Pharmacists,Physiotherapists,RespiratoryTherapistsandSpeech-LanguagePathologists.Thefundreimburses eligible fees for professional development activities that enhance skill, knowledge, practice and service delivery.

Objectives of the Allied Health Professional Development FundTheAlliedHealthProfessionalDevelopmentFund(AHPDF) improveshealthcareprofessionals’accesstoPDactivitiesinorder to:

• Advance clinical practice knowledge and skills to continuouslyimprovethequalityofpatientcare;

• Contributetotheprovisionofmoreeffectiveandefficienthealthcareservicedelivery;

• Advanceclinicalpracticesinpriorityhealthcareareasidentified in Patients First: An Action Plan for Health Care;

• Integrateevidenceintoprofessionalpractice;and

• Assist health care professionals to become change agents andadapt to changing expectations and patient health care needs.

Allied Health Professional Development Fund Application Form

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www.ahpdf.ca

click, learn, grow.Funding for AHPDF is provided by the Ontario Government.

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EligibilityAnapplicantmustmeetthefollowingcriteriatobeeligibleforAHPDFeducationgrants:

• Beahealthprofessionalincludedinthelistprovidedonthefirstpage(otherprofessionalsareineligible)

• BeregisteredwithhisorherOntarioregulatorycollegeatthetimeofparticipationinthePDactivity

• BecurrentlypracticingoreligibletopracticeinhisorherrespectiveprofessioninOntario

• NotbeemployedoutsideofOntario

• NothavealreadyreceivedAHPDFgrantstotaling$1,500inthecurrent fiscal year

Only fees paid by the applicant are eligible for reimbursement. Fees paid by businesses are not eligible. Applicationsfromemployerswillnotbeaccepted. Funds will not be transferred to a business bank account.

Reimbursable ExpensesGrants are to be used to pay for all or part of registration/tuition fees related to PD activities, whichincrease knowledgeandskills,completedbetweenApril 1, 2015 and March 31, 2016.ThePDexpensesmustbefor workshoporconferenceregistrationfeesorcoursetuitionfees.TheapplicantmustprovideaclearrationaletosupporthowthePDactivityisrelatedtotheapplicant’sareaofpracticeandhowtheactivitywillimprove the quality of patient care/services. Costs for books, travel, salary replacement, meals,accommodation,exams,memberships, and subscriptions etc. are not eligible for reimbursement.

Application Requirements1. Application Form

TheApplicationForm(pages3and4ofthisdocument)mustbecompleted and signed.ASocialInsuranceNumbermustbeincludedfortaxpurposes.RecipientsoffundingwillbeissuedT4Ainformationinaccordancewith the Income Tax Act. For information about Canadian income tax requirements, please visit theCanada RevenueAgency.Pleasenotethatallinformationprovidedtothe AHPDFisstrictlyconfidential.SeethePrivacy PolicyontheAHPDFwebsiteformoreinformation.

2. Proof of Payment

Anofficialreceipt(proofofpayment)issuedbythedelivererofthePDactivityclearlystatingtheprofessionalactivitynameandtheregistration/tuitionfeespaidisrequired.Onlyregistrationfeesorcoursetuitionfeesareeligibleforreimbursement.Invoiceswithanoutstandingbalanceand/orT2202Aformswillnotbeaccepted.Proofofexchangerateisrequiredforfeespaidinforeigncurrency(otherwisetheexchangeratevalidonthedateoftransactionwillbeapplied).Originalreceiptsarenotnecessary.Photocopiesareacceptable.

3. Proof of Successful Completion

A passing grade report, a course certificate, a certificate of attendance, a transcript from the educationalfacility,oraprintoutfromastudent-basedweb-servicestatingthestudent’snameandthecoursecompletiondateisrequired.Officialtranscriptsarenotnecessary.Photocopiesareacceptable.Originaldocumentswillnot be returned.

4. Void Cheque or Direct Deposit Form

Reimbursementswillbemadeusingdirectdeposit.Avoid chequeor completeddirectdeposit form isnecessarytotransferfundsintotherespectivebankaccount.Applicants’bankinginformationisheldinthestrictest confidence and used only for the purpose of direct deposit of the approved funding. Applicantssubmittingbyfaxareaskedtofaxacopyofthevoidchequeorcompleteddirectdepositform.Onlypersonalbanking account information will be accepted. Funds will not be transferred to a business account.

Submission Deadline

The application must be received within 90 days of the completion date of the professional development activity or by March 31, 2016, whichever date comes first. Late and/or incomplete applications will be declined. No exceptions will be made for late or incomplete applications. Declined applications cannot be resubmitted.

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Allied Health Professional Development Fund Application Form PLEASEPRINT(All fields must be completed. Late and/or incomplete applications will be declined.)

Employment Status: (Check one only)

Please click here for definitions of Employment Sectors.

Employed Full-Time or Part-Time in one of the eligible allied health professions

Unemployed/Not Employed in one of the eligible allied health professionsEmployment Sector: (Check one only)

AcuteCare CommunityCare

Long-TermCare Other____________________________

Employer’s Name (Organization Name): ________________________________________________________________________

PD Activity Name: ____________________________________________ Tuition/Registration Fee paid:$______________ (One eligible course per application. Each of the courses in a program with multiple courses must be submitted on a separate application form.)

Name of PD provider: ____________________________________ Start date: ______________ End date: _____________(The organization name) MM/DD/YY MM/DD/YY

Education Type: (Check one only)

Workshop/Conference/SpecialtyCourse Diploma/UndergradCourse Masters/PhDCourse PhDThesisCourse

Education Provider Type: (Check one only)

College or University HealthCare/ProfessionalAssociation PrivateBusiness PersonalTutor

Relevance to AHPDF objectives:How has the professional development activity advanced your clinical practice knowledge or skills and/or enabled you toimprovethequalityofpatientcare?

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Did your professional development activity apply to any of the following health care areas? (Check all that apply)

Which area will your PD activity impact the most? (Check one only)

Clinical/DirectPracticeKnowledgeorSkills HealthPolicy/HealthLeadershipKnowledgeorSkills

BusinessKnowledgeorSkills SecondLanguageKnowledgeorSkills

Other_________________________________________________________________________________________________

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This application form may not be used after March 31, 2016

Interprofessional Collaboration Chronic Disease Prevention and Management Mental Health Seniors Care Other ________________________________

Social Insurance Number: _____ - _____ - _____

Regulatory College: (check box) CMRTOCASLPOCMLTOCPOCOTOCDOOCPCRTO

College Registration Number: __________________

First Name: _________________________________________ Last Name: ____________________________________

Telephone: (______) __________________________________ Email: ________________________________________

Home Address: _____________________________________________________________________________________

City: ________________________________________________ Province: _______________ Postal Code: __________

Have you or will you receive reimbursement from any other source for the registration/tuition fees for which you are applying for AHPDF funding?

No Yes If yes, please state amount: $ __________ This amount will be subtracted from your request

Required for income tax purposes. For information about the AHPDF privacy policy, please visit www.ahpdf.ca.

The registration number must be provided on every application form.

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Additional InformationFundingisallocatedonaquarterlybasistoeacheligibleprofessionbaseduponsizeofmembership.Intheeventthattherequestforfundsinanyquarterexceedsthefundingallocatedtotheprofessionforthatquarter,eligibleunfundedapplicationsforthequarterwillbeplacedonholduntiltheendofthefiscalyearandconsideredatthattimeshouldfundingallow.Fundingisnotguaranteed.Moreinformation,includingFrequentlyAskedQuestions,canbefoundontheAlliedHealthProfessionalDevelopmentFundwebsiteatwww.ahpdf.ca.

Due to a high volume of submissions, AHPDF staff is unable to confirm the receipt of applications. The applicant will, however, be contacted by email to notify them about the status of their application within six weeks of the date on which the application was received. Program administrators reserve the right to validate information with the applicant and to request any additional documentation as required.

The applicant is required to keep copies of the application form, supporting documents, and fax confirmation or courier/registered mail receipt (if applicable) for their personal records. The applicant is required to notify AHPDF staff if their email or address changes. All information provided to the AHPDF is strictly confidential. Please see the Privacy Policy on the AHPDF website for more information. Applicants will be sent a year-end survey to collect information needed to evaluate the fund.

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Contact Information for SubmissionsMail: AlliedHealthProfessionalDevelopmentFund

5025OrbitorDrive,Building4,Suite200 Mississauga,ON,L4W4Y5

Fax: 905-602-6012/905-602-6078Email: info@ahpdf.ca (Please ensure that all required

documents are scanned and attached)

Need Assistance?Email: info@ahpdf.caPhone:905-602-6015/1-866-992-6015Web: www.ahpdf.ca

Late and/or incomplete applications will be declinedTheapplicationmustbereceivedwithin90 days of the completion date of the professional development activity or by March 31, 2016, whichever date comes first. Late/incomplete applications will be declined. No exceptions will be made for late/incomplete applications.

The following must be submitted as part of a completed application:1. cCompletedApplicationForm(complete all parts and sign below)

2. cProofofPayment(specifically showing registration/tuition fees paid for this PD activity)

3. cProofofSuccessfulCompletion;and

4. cVoidChequeorDirectDepositForm(personal bank accounts only)

Bysigningbelow,IdeclarethatIhavereadandunderstoodtheapplicationandtheeligibilitycriteria,as well as any implications of receiving reimbursement and that all information is true and complete.

______________________________________________________________ Signature of Applicant (please sign by hand)

__________________________ Date (MM/DD/YY)

This application form may not be used after March 31, 2016