Northwest Colorado Healthcare All-Hazards Conference Reimbursement Form

This process will be used to collect and manage the travel reimbursement for all Northwest Colorado Healthcare All-Hazards Conference attendees. Travel costs will only be allowed based on the GSA Per Diem Rates and the IRS Mileage rates (see below). One form is required per trip, for each traveler.

Mileage - at the IRS rate (https://www.irs.gov/tax-professionals/standard-mileage-rates). Provide proof of miles driven (e.g. Google map) and upload document to this survey.

It is up to each conference attendee to abide by the reimbursement rules established by the NWRHCC.

Question Title

* 1. Please enter your contact information.

Name *

Company *

Email Address *

Phone Number

Question Title

* 2. Enter the information for the reimbursement check. Include who the check should be made out to and a mailing address for the check.

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Question Title

* 3. Enter the date(s) of Northwest Colorado Healthcare All-Hazards Conference-related travel.

Question Title

* 4. Enter the location (city, state) for Northwest Colorado Healthcare All-Hazards Conference-related travel.

Question Title

* 5. Complete and upload the Northwest Colorado Healthcare All-Hazards Conference Travel Reimbursement Form in Word, PDF, or JPEG/JPG format.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

* 6. Upload proof of the mileage traveled (e.g. Google Map) in Word, PDF, or JPEG/JPG format.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

* 7. Enter the total amount requested (mileage).

Question Title

* 8. Completion of the information below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information provided.

I, the Requester, understand that I am requesting reimbursement from grant funds from the Northwest Region Healthcare Coalition and that such funds are restricted under the guidelines set forth by the Hospital Preparedness Program and the Governance of the Northwest Region Healthcare Coalition. I verify that this reimbursement request does not pose any potential conflict of interest for any Steering Committee member and that I will provide any documentation required by the Steering Committee and/or fiscal agent to authorize payment or review of the appropriateness of the request.

Name

Title

Date