Rural Ready NP Scholars 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.

As a Scholar, you are eligible to submit up to $3,000 of travel reimbursements during the academic year (fall, spring, summer). The mileage reimbursement rate is $0.56/mile.

You are also eligible to submit up to $300 for resource reimbursement. The resources must be from the approved ANEW list.

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

If your travel reimbursement is for a designated clinical or educational experience, please complete the following section. If it was not, please proceed to the appropriate reimbursement section.

Clinical or Educational Experience

What course was your clinical or educational experience for?

If specifically for ANEW Scholars, please note that.

Who is your instructor for this course?

If for ANEW Scholars, please note that.

Date of Departure

Time of Departure

:HourMinutesAM/PM Option

Date of Return

Time of Return

:HourMinutesAM/PM Option

Where did you travel to?

Where did you travel from?

Name of Healthcare Facility or Meeting Location

Name of the preceptor you worked with the most.

Hours spent providing direct or indirect care.

Mileage Reimbursement

Reimbursement Rate: $0.56/mile

Are you requesting mileage reimbursement?*

YesNo

Total miles traveled (roundtrip).

Please list names of students who rode with you.

Airfare Reimbursement

Reimbursement Rate: Up to $500 (EM Boot Camp)

Are you requesting airfare reimbursement?*

YesNo

Upload receipt.

Browse Files

Upload here.

Lodging Reimbursement

Reimbursement Rate: up to $96/night + tax

Are you requesting lodging reimbursement?*

YesNo

Please list names of students who shared lodging with you.

Upload receipt.

Browse Files

Upload here.

Registration Reimbursement

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

Upload receipt.

Browse Files

Upload here.

Resource Reimbursement

If you purchased a resource (i.e. book, online subscription) from the approved purchasing list, please upload your receipt here.

Upload receipt.

Browse Files

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*