Rural Pharmacy Student Placement Allowance (RPSPA) Program - Application Form Eligibility Was your placement in your home town or university campus town? * Yes No Unfortunately as you do not meet the eligibility criteria to apply for this reimbursement. Are you an Australian citizen, permanent resident, or have permanent resident status? * Yes No Unfortunately as you do not meet the eligibility criteria to apply for this reimbursement. Personal InformationStudent Number * Given name * Surname * Email address * Gender Address * (Street) Address * (City/Town) Placement detailsPlacement Agency Name and Town * Placement State * Victoria New South Wales Queensland Northern Territory Western Australia South Australia Australian Capital Territory Tasmania Placement Dates (from - to) * (please use format dd/mm/yyyy - dd/mm/yyyy) Year Level * 2nd 3rd 4th Modified Monash (MM) Category (Your placement must be in MM 3-7 for you to be eligible to claim a reimbursement): * Please check the MM category of the placement location here: Health Workforce Locator. When the website opens there will be a Classification Filter box, You will need to tick the box next to 2019 then click the Find address button. This will give a drop down to type in the address of your placement agency. It will then state in the Classification Filter box which MM category your placement is in and the address will be highlighted on the map. The Rural Pharmacy Student Placement Allowance Have you been awarded any other allowance, grant or prize to assist you to undertake University studies? * Yes No Please provide details (name and value) of allowance, grant or prize you have been awarded. * Are you a member or past member of any relevant groups, societies or organisations that you believe have relevance to this application? * Yes No Please provide details of any groups, societies or organisations that you believe have relevance to this application. * The Rural Pharmacy Student Placement Allowances are awarded to pharmacy students to encourage pharmacist recruitment and retention in rural and remote areas. * Please write a brief statement demonstrating your awareness of rural practice issues and rural health issues. Please write a brief report detailing the activities undertaken while on placement. * Are you claiming a reimbursement for personal car usage? * Yes No PERSONAL CAR USAGE REIMBURSEMENT GUIDELINES -You can claim a mileage reimbursement at a cents per kilometer allowance when using your private motor vehicle for this placement travel. -The rate is set by the ATO (please use the rate relevant to the financial year in which you travelled). This claim can include ALL placement kilometers travelled in personal car: -From place of residence to accommodation while on placement -To and from placement daily -Return to place of residence after placement Number of kilometers travelled in personal car? * Amount ($) of reimbursement for kilometres travelled in personal car * Please provide an explanation of total kilometers travelled and show your rate calculation: * Are you claiming a reimbursement for flights? * Yes No Amount ($) of reimbursement for flights * Are you claiming a reimbursement for public transport/taxi/ride share? * Yes No Amount ($) of reimbursement for public transport/taxi/ride share * Are you claiming a reimbursement for accommodation? * Yes No Amount ($) of reimbursement for accommodation * Total amount ($) of your reimbursement request * Supporting Documentation - please combine all documents into a single attachment. * PERSONAL CAR USAGE - You can claim reimbursement at the flat rate of .78 cents per Kilometer driven in personal car. SUPPORTING DOCUMENTATION - screenshot of distance in kilometers (eg: google maps screenshot indicating distance travelled). Note: there is no separate claim for fuel, only the flat rate for usage.FLIGHTS - You can claim reimbursement for flights to/from placement. SUPPORTING DOCUMENTATION - Tax InvoiceOTHER TRANSPORT - You can claim reimbursement for Public transport/taxi/ride share. SUPPORTING DOCUMENTATION - invoice or receipt ACCOMMODATION - You can claim reimbursement for Accommodation while on placement.SUPPORTING DOCUMENTATION - invoice or receiptSingle file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio Please provide a brief explanation/breakdown of your claim * AcknowledgementBy submitting this form I acknowledge that all the information provided is correct * Yes - Agree Validation Privacy Statement La Trobe University respects the privacy of your personal information. Collection of personal information is solely for the purpose of submitting the reimbursement application for the Rural Pharmacy Student Placement Allowance (RPSPA) Program. If your personal information is not provided to us then we cannot process your reimbursement. In accordance with privacy laws, personal information about you contained in your application will not be used for any other purpose or disclosed to any person who is not part of the La Trobe RPSPA Program assessment and reimbursement process, without your permission. Details regarding collection, use, disclosure and access of personal information from this form are available at: www.latrobe.edu.au/privacy or by emailing LRHS.PharmacyPlacements@latrobe.edu.au.
