Student Clerkship Travel Request Form – HRSA Medical MSE Grant Student Clerkship Travel Request under the HRSA Medical Student Education Grant Date(Required) MM slash DD slash YYYY Student's Name(Required) First Last Student's Email(Required) Student ID #(Required) Travel Dates(Required) mm/dd/yyyy – mm/dd/yyyyThis request is supported within the narrative of the budget.(Required) Yes If yes, please select a justification category for your request.(Required)Please select one of the following:Administration Authorized Student Travel (in-state/local)Administration Authorized Student Travel (out-of-state/long distance)This request supports Objective 2 of the HRSA Grant:(Required) Yes Increase community-based field placement and experiential training opportunities in rural and/or MUC primary care clinical training sites by expanding strategic partnerships across the state.Purpose of Travel(Required) Junior Clerkship Rotation at a Regional Center Junior Clerkship Rotation at a Community Health Clinic (CHCA Rotation) Senior Clerkship Rotation Location of Clerkship Rotation(Required) UAMS Northeast – Jonesboro UAMS Northwest – Fayetteville UAMS North Central – Batesville UAMS South Central – Pine Bluff UAMS Southwest – Texarkana UAMS West – Fort Smith CHCA Multi-Site Rotation: River Valley, East AR Family Health, Mainline Processor's Name(Required) First Last Processor's Email(Required) Please use the space below to provide the name and address of the hotel(s) for this trip. For the CHCA multi-site rotation, list the hotels and addresses with check-in/check-out dates. Please be aware that all UAMS trips must comply with state travel regulations and national per diem rates. If your requested hotel(s) exceeds per diem rates, please provide an alternative location or the travel processor will find an alternative within the acceptable rate. If this is the best location available and still exceeds the national rate, you will need to fill out an exception form specifying the reason for the additional cost.Will you need meal reimbursement for this trip?(Required) Yes No (Available if housing does not provide kitchen access)Will you need mileage reimbursement for this trip?(Required) Yes No (Available for CHCA Rotations only)Attach the Vendor Setup Form and W9 here: Drop files here or Select files Max. file size: 15 MB. Please upload any documentation providing justification for travel. This can include any clerkship documentation such as: orientation materials, schedules, sign-in sheets, etc. Drop files here or Select files Max. file size: 15 MB.