MHTP Travel Reimbursement Form

MSU nursing students will demonstrate behaviors that are congruent with the MSU Code of Conduct, CON Student Handbook, ANA Code of Ethics, Scope and Standards of Practice, and Social Policy Statements in all program related interactions. Please keep this in mind as you complete the reimbursement form.

Name:*

First NameLast Name

GID Number*

(Student ID Number ex: -01234567)

E-mail Address:*

Address to Mail Check:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select which program you are in (select all that apply):*

MHTPCO-OPDNPOther

If you are NOT in the MHTP, please fill out this demographic form: https://montana.qualtrics.com/jfe/form/SV_cBg3xnhOhTP3HOm

After you complete the form linked above, please return to this form to apply for reimbursement. We will not be able to reimburse you until both forms are completed.

If you are a BSN student in MHTP, you do not need to fill out the qualtrics form linked above and can proceed with the reimbursement form.

Clinical Experience

What course was your clinical experience for?*

Who is your instructor for this course?*

Travel reimbursement requests will be processed upon course instructor approval.

Date of Departure*

Time of Departure*

:HourMinutesAM/PM Option

Date of Return*

Time of Return*

:HourMinutesAM/PM Option

Clinical town traveled to?*

Home campus city traveled from?*

Name of Healthcare Facility*

Name of the preceptor you worked with the most.*

Hours spent providing direct or indirect care.*

Mileage Reimbursement (personal vehicles only)

Reimbursement Rate: $0.70/mile

Your total mileage reimbursement will be calculated based on the distance traveled from your home campus to the city where the clinical site is located and back. This may not be the exact miles you traveled, as it is just city to city. If multiple students carpooled, only the student who used their car should submit for mileage reimbursement.

i.e. If you are a student at the Billings campus traveling to Rosebud Health Care Center in Forsyth, your mileage will be the distance from Billings to Forsyth. This is 99.5 miles one way (199 miles roundtrip), according to Google Maps.

Are you requesting mileage reimbursement? If yes, please answer the questions below*

YesNo

Total miles traveled (roundtrip).

Please list names of students who rode with you.

Gas Receipts (rental vehicles ONLY!)

Are you requesting gas reimbursement?*

YesNo

Please upload your gas receipts. Clear photos are acceptable.

Browse Files

Airfare Reimbursement

Please upload a copy of your flight receipt and proof of travel (boarding pass).

Are you requesting airfare reimbursement?*

YesNo

Please upload flight receipt and proof of travel. Clear photos are acceptable.

Browse Files

Lodging Reimbursement

Reimbursement Rate: we can only guarantee reimbursement up to $110/night + tax per person. If your lodging was more than that, you will need to provide justification. We will try to reimburse your cost, but it is not guaranteed that more than $110/night + tax will be reimbursed. When sharing lodging, only the student who has a paid receipt in their name should request reimbursement. Students should work out shared expense between each other.

Are you requesting lodging reimbursement? If yes, please answer the questions below.*

YesNo

Is your lodging cost greater than $110/night?*

YesNo

If your lodging cost was greater than $110/night + tax, please provide a justification for this increased expense (i.e. unable to find state rate room in area with a reference to other hotels you checked). If your lodging was $110 or less, write N/A*

Please list names of students who shared a room with you.

Please upload lodging receipt. Clear photos of receipts are acceptable.

Browse Files

Meal Reimbursement

Are you requesting meal reimbursement? If yes, you must enter your meal information below.*

YesNo

In-State Reimbursement Rate: Breakfast (leave before 7 AM)- $11.20 / Lunch (leave before 12 PM/return after 1 PM)- $13.30 / Dinner (return after 6 PM)- $19.60 (the state rate)

# of Breakfasts

# of Lunches

# of Dinners

Registration Reimbursement

If you attended a conference or training and paid for the registration yourself, please upload your receipt here.

Please upload registration receipt.

Browse Files

W-9 Upload

The IRS W-9 Form can be found on reimbursement homepage. Please complete and sign Page 1. Signatures must be in cursive.

Please upload W-9 Form. *

Browse Files

Must include Page 1 of W-9.

Signature

I confirm that the information given in this form is true, complete and accurate. *

Sign with mouse or finger above the line.

Today's Date*