Student Clinical 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 Name Last Name

GID Number *

(Student ID Number ex: -01234567)

E-mail Address: *

Address to Mail Check: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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 *

: Hour Minutes AM/PM Option

Date of Return *

Time of Return *

: Hour Minutes AM/PM Option

Where did you travel to? *

Where did you travel from? *

Name of Healthcare Facility *

Name of the preceptor you worked with the most. *

Hours spent providing direct or indirect care. *

Mileage Reimbursement

Reimbursement Rate: $0.585/mile

Your total mileage reimbursement will be calculated based on the distance traveled from your home campus to the clinical site and back.

Are you requesting mileage reimbursement? *

Yes No

Total miles traveled (roundtrip).

Please list names of students who rode with you. *

Lodging Reimbursement

Reimbursement Rate: up to $96/night + tax

Are you requesting lodging reimbursement? *

Yes No

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

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

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Meal Reimbursement

Reimbursement Rate: $7.50/breakfast, $8.50/lunch, $14.50/dinner.

# 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.

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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. *

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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. Clear

Today's Date *