Verification of Relevant Nursing Experience

Name ____________________ Start Date: __________________

Please return to: AddPayChallengeNBA@interiorhealth.ca
Name of Job Title Dates of Employment Status If Casual: For HR Use Only
Employer From To FT/PT/Casual # Hours Calculated Calculated
(MM/YYYY) (MM/YYYY) Worked/Week Months/Years Hours

To be eligible to receive recognition of previous nursing experience for the purposes of Year 15 – 30 Add Pay, you must provide
supporting documents such as Confirmation of Employment and Seniority Hours from a previous employer(s) attached to this
completed form.
Employee Attestation:
I, ___________________, hereby certify that the information given on this form and any attached supporting documentation is
true and correct. I understand that if this attestation is found to be false or untrue it may result in discipline.
Date: ___________________________ Nurse Signature: ____________________________
 Guidelines for Completion
Please follow the below instructions to ensure we are able to correctly determine any adjustments to your Year 15 -30 Add Pay eligibility date:

1. If claiming casual hours, clearly state whether they are your weekly, monthly or the total hours worked.

2. Write one experience per line in the provided table. Do not combine multiple experiences or statuses (full-time/part-
time/casual) in one line.

3. Do not combine casual and regular experience in one line. If you worked regular and casual concurrently at the same
employer, clearly indicate your status per line.

4. Do not combine experience worked as a LPN with experience worked as a RN/RPN in one line. Experience worked as a
LPN must have its own line.

5. Dates of employment must be in the format (MM/YYYY).