NHS Student Bursaries - Practice PlacementExpenses:Request for approval for the use of privatevehicles

Please refer to the NHS Student Bursaries website for full information about claiming practiceplacementexpenses

The current guidelines for the use of a privately owned vehicle are that public transport fares must be claimedifthese are lower unless public transport is unavailable orunsuitable.

If you wish to use your own vehicle please complete the following information and submit the form totheStudent Services Office with any required evidence. Please note that authorisation from the collegeregardingthe use of private vehicles is required BEFORE the placementcommences.

StudentName
Year of entry toprogramme
Placement sitename
Student residentialaddresswhilst onplacement
Academic Term address(ifdifferent to placementaddress)
Is there publictransportavailable to yourplacementsite? / Yes /No
If yes, is itsuitable? / Yes /No
If No, please state why and submit supporting evidence(egtimetables etc) demonstratingthis:
What is the total daily mileage between your placement address andyourplacementsite?
Whatisthetotaldailyfareforyoutotraveltoyourplacementsitebypublictransport?Pleasesubmitsupportingevidenceofthisfare(e.g.leaflet) / £
DriversLicence / Comments
No / ExpiryDate
VEHICLEDETAILS
Type(egcar,
motorcycle) / Make(egFord) / Model
(egEscort) / Enginecapacity
(eg1600cc) / Age / RegNo
1
2
Is (are) yourvehicle(s):
Taxed? / Roadworthy:Ifrequired, doesithave an MOTCertificate? / Adequately insured (in your name, including cover driving to andfromyour placementsite?)
Note: you may need to contact your insurance company or brokertodiscussthis
Y / N / Y / N / Y / N
Until(date): / RenewalDate: / InsuranceCompany:
CertificateNo. / PolicyNo.
Ideclarethatalltheabovestatementsaretrueandthatuseofmyprivatevehicletoandfrommyplacement siteis:
NECESSARY / MY PERSONALCHOICE*
*deleteasapplicable,pleaseattachdetails/reasonstosupportthisstatement
Signed______Dated______(Driver)

For staff useonly

StudentName
Intheopinionofthecommitteeispublictransportavailableandsuitable?Yes - go to number1
No - go to number2Comments:
1. If public transport is suitable, the student may claim for the least expensive option out ofthepublic transport fare or the carmileage
2. As public transport is not suitable the student may claim theirmileage
Please indicate here whether the student may claim mileageforthe use of a privately owned vehicle, or for the publictransportfare: / Mileage / Public TransportFare
Date ofMeeting:
Date student notified (via email) including whether they can claim for mileage or for thepublictransportfare:

______PlacementCo-ordinator