Conference Attendance Request

Complete this form when your travel will expend or likely expend ASPR funding.

Region*
Conference Information
Conference/Training/Educational Event*
Date of Arrival*
Date Format: MM slash DD slash YYYY
Date of Departure*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Estimated Expenses
Registration
Lodging
Travel
Per Diem
Miscellaneus
Total
$0.00
Conference Details and Justification
Details and Justification*
How will attendance at this conference enhance your facility and/or region's preparedness?
Attendees

Attendees

Name	Title	Email

Supporting Documentation Upload
Accepted file types: jpg, gif, png, docx, doc, pdf, xls.
Transmittal
Upon submission, the Regional Hospital Coordinator will receive this form and review. From there, all requests must go to VHHA and to VDH. By submitting this form, the submitter certifies that these estimates have been arrive at through research and due diligence. Please be cognizant that approval of travel and attendance does not cover all expenses. Only expenses permitted by your regional coalition will be recovered. Responses to travel requests are typically returned within 7-10 business days.
Name of Submitter*
First Last
Submitter Email*
Enter Email Confirm Email
Submitter Phone Number

Conference Information