NDLSF Instructor Reimbursement & Assessment Form InstructionsPlease complete this form when seeking reimbursement from NSPA for approved expenses. Reimbursement may take up to 60 days processing and delivery. A copy of this form will be presented once submitted.NDLSF Instructor ResourcesReimbursement & Assessment(select a type of reimbursement)TravelNDLSF InstructionNDLSF Peer AssessmentOther ExpensesGeneral InformationName* First Last Email* OrganizationWho should the check be made out to? The submitter The organization Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TravelSelect the number travel days belowNumber of Days*12345Date* Date Format: MM slash DD slash YYYY Travel DayYesNoMeals Included Breakfast Lunch Dinner Check the box below if the meal was provided for you by the hostMileage (In Miles)Date* Date Format: MM slash DD slash YYYY Travel DayYesNoMeals IncludedCheck the box below if the meal was provided for you by the host Breakfast Lunch Dinner Mileage (In Miles)Date* Date Format: MM slash DD slash YYYY Travel DayYesNoMeals IncludedCheck the box below if the meal was provided for you by the host Breakfast Lunch Dinner Mileage (In Miles)Date* Date Format: MM slash DD slash YYYY Travel DayYesNoMeals IncludedCheck the box below if the meal was provided for you by the host Breakfast Lunch Dinner Mileage (In Miles)Date* Date Format: MM slash DD slash YYYY Travel DayYesNoMeals IncludedCheck the box below if the meal was provided for you by the host Breakfast Lunch Dinner Mileage (In Miles)NDLSF InstructionCheck the box below for the sections taught:BDLS® Disaster Basics Natural Disasters Workforce Readiness & Deployment Chemical Disasters Mass Casualty & Fatality Management Explosive & Radiologic Disasters Public Health & Population Health Biologic Disasters BDLS®* Date Format: MM slash DD slash YYYY ADLS® Day 1Full DayHalf DayADLS® Day 1 - Full Day* Date Format: MM slash DD slash YYYY ADLS® Day 1 - Half Day* Date Format: MM slash DD slash YYYY ADLS® Day 2Full DayHalf DayADLS® Day 2 - Full Day* Date Format: MM slash DD slash YYYY ADLS® Day 2 - Half Day* Date Format: MM slash DD slash YYYY CHEC® Day 1 Day 2 Day 3 CHEC® Day 1* Date Format: MM slash DD slash YYYY CHEC® Day 2* Date Format: MM slash DD slash YYYY CHEC® Day 3* Date Format: MM slash DD slash YYYY NDLSF Peer AssessmentInstructor being assessed:*Lindsey AnthonyBobby BakerCharles BergerKen BishopPaige BordwineCraig CamidgeRick ChristJT ClarkRon ClinedinstMark CromerGrady DeVilbissKeith DowlerRobert FeinbergTom FirebaughRoger GlickDr. Mark HamillCaren HerringArchie HirschmannAdam LaChappelleDr. Charles LaneDavid LinkousMonica McCulloughGary MeadowsShawn MetznerMichael PruittJohn RyanDallas TaylorTammy TurpinKari WhitneyThe instructor came prepared and on time:*5 (Best)43210 (Worst)The instructor stuck to the schedule:*5 (Best)43210 (Worst)The instructor stuck to the material:*5 (Best)43210 (Worst)The instructor engaged the audience:*5 (Best)43210 (Worst)The instructor's top strength:The instructor's top area for improvement:Other ExpensesItemized ExpensesDate (MM/DD/YY)Description of Expense/ItemAmount (in dollars) Supporting DocumentationSupporting DocumentationSupporting DocumentationSupporting DocumentationAssessment* I hereby attest that I have submitted the peer assessment. Attestation* Submitting is Your Signature I hereby attest that the above request for reimbursement is accurate and complete to the best of my knowledge and agree that NSPA has the right to refuse any amount/expense deemed ineligible by policy, regulations, and/or law.
