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Faculty, Fellow, Staff

Travel Reimbursement

  1. Name:

  2. E-mail:

  3. Division:

    Body Imaging
    Musculoskeletal Imaging
    Nuclear Medicine
    Vascular & Interventional
    Women's Imaging

    Radiology Resident

    Administrative Support Staff

  4. Name of Society Meeting:

  5. Meeting Location (City, State):

  6. Dates of Meeting:      to

  7. Nature of Participation:
  8. Paper Presentation
    Meeting Administration
    Departmental Leave


  9. Number of paper(s), poster(s), etc. to be presented at the meeting:

    1      2      3      4      5

  10. Date(s) you will be giving presentation(s):

  11. Topic of presentation:

  12. Abstract/letter of acceptance or other pertinent documentation attached: Yes No
    (If not attached, reimbursement will be denied.)


  13. I have explored all other sources potentially available for support of this trip: Health Research Association (HRA), relevant grants or contracts, institutional support, etc.

    I have received $ in support of this trip.

    Sponsor Name:

    No other support was available.

  14. Measurable benefit to the Department:
    (For Departmental Leave):

  15. Please state any special considerations(s) you feel might be important to help expedite the approval process:

    * All expenses accumulated during the trip must be supported with receipts or copies of canceled checks.




To be Completed 4 Weeks Prior to Trip



Document last modified Wednesday, January 28, 2009.
2002 University of Southern California