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* Organization Who should the check be made out to? The submitter The organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TravelSelect the number travel days belowNumber of Days*12345Date* MM slash DD slash YYYY Travel Day Yes No Meals Included Breakfast Lunch Dinner Check the box below if the meal was provided for you by the hostMileage (In Miles)Date* MM slash DD slash YYYY Travel Day Yes No Meals IncludedCheck the box below if the meal was provided for you by the host Breakfast Lunch Dinner Mileage (In Miles)Date* MM slash DD slash YYYY Travel Day Yes No Meals IncludedCheck the box below if the meal was provided for you by the host Breakfast Lunch Dinner Mileage (In Miles)Date* MM slash DD slash YYYY Travel Day Yes No Meals IncludedCheck the box below if the meal was provided for you by the host Breakfast Lunch Dinner Mileage (In Miles)Date* MM slash DD slash YYYY Travel Day Yes No Meals 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®* MM slash DD slash YYYY ADLS® Day 1 Full Day Half Day ADLS® Day 1 - Full Day* MM slash DD slash YYYY ADLS® Day 1 - Half Day* MM slash DD slash YYYY ADLS® Day 2 Full Day Half Day ADLS® Day 2 - Full Day* MM slash DD slash YYYY ADLS® Day 2 - Half Day* MM slash DD slash YYYY CHEC® Day 1 Day 2 Day 3 CHEC® Day 1* MM slash DD slash YYYY CHEC® Day 2* MM slash DD slash YYYY CHEC® Day 3* MM slash DD slash YYYY NDLSF Peer AssessmentInstructor being assessed:*Bobby BakerKen BishopPaige BordwineRick ChristChris ChristensenJT ClarkRon ClinedinstMark CromerGrady DeVilbissDavid EnglishRobert FeinbergTom FirebaughMike GarnettRoger GlickDr. Mark HamillRobert HawkinsArchie HirschmannAdam LaChappelleDr. Charles LaneMonica McCulloughGary MeadowsMichael PruittJordan RennieJohn RyanAshley ShifflettDallas TaylorTammy TurpinKari WhitneyThe instructor came prepared and on time:* 5 (Best) 4 3 2 1 0 (Worst) The instructor stuck to the schedule:* 5 (Best) 4 3 2 1 0 (Worst) The instructor stuck to the material:* 5 (Best) 4 3 2 1 0 (Worst) The instructor engaged the audience:* 5 (Best) 4 3 2 1 0 (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 DocumentationMax. file size: 50 MB.Supporting DocumentationMax. file size: 50 MB.Supporting DocumentationMax. file size: 50 MB.Assessment* 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.