REP Travel Request Form – HRSA MSE Grant REP Travel Request under the HRSA Medical Student Education Grant Date - must be mm/dd/yyyy format(Required) MM slash DD slash YYYY Name(Required) First Last Traveler's Email(Required) Traveler's SAP #(Required) Travel Dates(Required) mm/dd/yyyy - mm/dd/yyyyActual Business Dates(Required) mm/dd/yyyy - mm/dd/yyyyIs this request supported within the narrative of the budget? Yes No If yes, please select a justification category for your request.Please select one of the following:Lunch and Learn EventAdministration Authorized Student Travel (in-state/local)Administration Authorized Student Travel (out-of-state/long distance)Faculty/Staff Travel (in-state/local)Faculty/Staff Travel (out-of-state/long distance)MD2BStudent recruitment eventSummer STEM AcademyRegional Programs/DFPM Annual UpdateHBCU Medicine Mentorship MixerWhich grant objective is satisfied by your request?Objective 1: Enhance pre-medical pipeline recruitment and retention strategies to increase the number of students from Arkansas’ rural and/or MUCs enrolling in the UAMS College of Medicine (COM), and who ultimately return to practice in rural and/or MUC primary care settings in Arkansas.Objective 2: 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.Objective 3: Expand UAMS COM pre-clinical experiences, clinical rotations, service projects, and other opportunities to increase medical student knowledge, skills, and abilities related to HRSA Core Topics and service in rural and/or MUC settings.Objective 4: Develop and implement an interprofessional Faculty/Staff Development series designed specifically for new FQHC and CAH teaching clinicians.Objective 5: Improve all communications, incentives, and recruitment approaches to attract more students to new and existing rural/underserved/primary care experiences and initiatives.Objective 6: Improve standardization and evaluation processes to effectively document, track, measure and disseminate findings and outcomes for this project and all community—based primary care initiatives.Event Name(Required) Purpose of Travel(Required)Address of the location to which you are going:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Will you need a hotel for this trip?(Required) Yes No Will you need a rental vehicle for this trip?(Required) Yes No Will you need a flight booked for this trip?(Required) Yes No Will you need mileage reimbursement for this trip?(Required) Yes No Please use the space below if you have any specific travel requests for this trip such as a specific flight or hotel location. Please be aware that all UAMS trips must comply with state travel regulations and national per diem rates. If your requested flight or hotel exceeds per diem rates, the travel processor will find an alternative within the acceptible rate or you will need to fill out an exception form specifiying the reason for the additional cost.Specific flight or hotel request documentation. Drop files here or Select files Max. file size: 15 MB. Please use this to upload any documentation you have that shows proof of your intended attendance of this event. This can include flyers for the event, event agenda, organizers confirmation email, or anything else that you think might work for showing the Travel Department proof of this trip. If using an e-mail, please try to use Outlook to save it as a PDF before uploading it to this form. You may also just forward that email confirmation to your travel processor. Drop files here or Select files Max. file size: 15 MB.
