RRSSC Request

The RRSSC is only for staffing requests directly related to an active COVID-19 outbreak in which staff shortages are impacting resident care. Requests are limited to short term assistance and are not intended to be a long-term staffing solution.

State funded staffing resources are:

Limited in capacity
Available for facilities experiencing staff shortages as a direct result of COVID-19
Funds are temporarily intended to bridge the gap while facilities stabilize their workforce

Facilities must continue to actively recruit and retain full time staff in order to receive the temporary funding support.

Please complete this form to request assistance from the RRSSC. Your request will be reviewed, and you will be contacted directly for follow-up.

First Name(Required)

Last Name(Required)

Position/Title(Required)

Phone Number(Required)

Email(Required)

Facility

Facility Name(Required)

Facility ID - CCN

Facility ID - State ID

Street Address(Required)

City(Required)

County(Required)

Zip Code(Required)

COVID-19

If yes, what date did the outbreak begin?

As of today, how many COVID-positive residents are in-house?

As of today, when does resident isolation end?

How many staff are currently out as a result of COVID-19?

RNs Out

LPNs Out

CMAs Out

CNAs Out

Leadership Staff Out

When are these staff expected to return to work? Please note the date the first staff member returns and the date the last staff member is expected to return.

Date first RN returns

Date last RN returns

Date first LPN returns

Date last LPN returns

Date first CMA returns

Date last CMA returns

Date first CNA returns

Date last CNA returns

Date first Leadership member returns

Date last Leadership member returns

Staffing

Please describe the nature of your staff shortage and the impact that this shortage has had on the residents/clients you serve.

Please describe current efforts to retain current staff and attract new staff.

Are you already working with an agency? If so, please list the ones you hold active contracts with.

If yes, when?

Attestation Statements

I verify that the requested staff will be used to address a short-term, COVID-19 outbreak-related staff shortage.
I verify that the facility is actively recruiting for permanent staff.
I verify that the facility will not separately bill to, or be reimbursed by, an insurance provider for staffing services provided by the RRSSC.

Phone

This field is for validation purposes and should be left unchanged.

RRSSC Request Form

Facility

COVID-19

Staffing