/
OUT-OF-STATE TRAVEL
JUSTIFICATION AND AUTHORIZATION
/ Contact Name:
Contact Phone #:()
Section 1 - Traveler Information
Name of Traveler: / Traveler’s Work Phone #:
Cluster-Office-Section-Unit:
Management Represented Volunteer Board/Commission Other
Section 2 - Trip Details
Event Name Location (city/state):/
Event (date/time):/through / / Are you receiving training? Yes No
Start Official Business (date/time): / / End Official Business (date/time): /
SIDE TRIP: Is Vacation/Personal Time requested in connection with the trip? Yes No Dates:

Section 3 – Justification and Documentation

Criteria for Travel (check all that apply and attach supporting documentation): Federal Grant/Legal Client Transport Revenue Generating Other

Technical Training Required Class/Cert. Reimbursed Travel – by at %

Are there multiple-travelers attending this same event? Yes No

If “Yes,” list names:

Justification:

Section 4 - Estimated Cost of Trip Funding Source: (Input all that apply)

Index
/ PCA / Funding Source / General Fund
% / Federal Funds
% / Lottery Funds
% /

Other Funds%

/ TOTALS
Hotel/Address/Phone #:
Conference Hotel? / Over per diem approved? Yes No______
Assistant Director Initial
Lodging: DailyPer Diem $0.00 / Daily Room Rate $0.00 / # of Nights {AMOUNT}
Meals: Daily Per Diem $0.00 / # of Breakfasts {AMOUNT} / # of Lunches {AMOUNT} / # of Dinners 0
Mode of Travel: / State Vehicle: Yes NoPrivate Vehicle: Yes NoAir: Yes No
Train: Yes NoBus: Yes NoOther:
Registration Fee(s): List-
Misc. Expenses: List - (i.e. lodging tax, parking, shuttle/taxi, etc)
TOTAL ESTIMATED COST OF TRAVEL: / $0.00

Section 5 – Authorization

Traveler / Date / Office AdministratorDate
Supervisor / Date / Assistant/Deputy Assistant Director (or delegate)Date
Program Support Manager / Date / DHS Director or Deputy Director Date
[Required for Assistant Director’s Travel Only]

Instructions

Please read carefully. Please type or print the information. Do not use abbreviations.

Section 1:Traveler Information

  • Input information as requested.

Section 2: Trip Details

  • Fill in dates and times for Event and Start/End of Business.
  • For coding purposes, please note if traveler is receiving training.
  • If vacation/personal time is requested, please provide the dates.

Section 3: Justification and Documentation:

Criteria for Travel

  • Federal Grant: Attach copy of grant page for proof of required attendance.
  • Client Transport: Include the patient or case number. If the transport is for a child, please attach a “Consent to Travel” form (CF0002) for each child.
  • Revenue Generating: Invitation indicating attendance is a critical grant requirement
  • Technical Training: Training not available in Oregon
  • Required Class or Certification: Memo stating requirements
  • Reimbursed travel: Invitation from Sponsor and documents indicating how sponsorship will be paid.
  • Other: Please explain under ‘Justification’ and attach documentation

Justification

Please state in 50 words or less what the need for travel is, i.e., why it’s important to DHS.

Single-Traveler Justification:

  • Briefly explain how attending this event impacts your current position or role, using “Criteria for Travel” under “Section 3”.

Multiple-traveler Justification:

If this travel authorization is for multiple-travelers, please justify the need for multiple parties to attend this event by:

  • Briefly explaining how attending this event impacts your current position or role, using “Criteria for Travel” under “Section #3”, and addressing any other needs such as:

Concurrent Sessions

Grant Requirements

Documentation

All Travelers

  • Attach agenda or invitation to the event
  • Attach required documentation to support the “Criteria for Travel” and “Justification” sections of this form
  • Make a copy of the Out-of-State Travel Authorization form and forward to Deputy Director. Maintain original and all supporting documents in cluster office to be included with travel expense claim form.

Section 4:Estimated Cost of Trip

Complete all applicable fields

Section 5:Authorization

Signatures indicate the form has been reviewed for accuracy as follows:

  • Traveler: Verifies provided information is accurate to the best of your knowledge.
  • Supervisor: Verifies that this travel is within the traveler’s scope of work or current role.
  • Program Support Manager: Verifies business need, and that funds are available for travel.
  • Administrator: Verifies funds available for expenditure.
  • Assistant/Deputy Assistant Director (or delegate): Verifies travel is necessary and complies with current DHS policy and administrative restrictions.