Origin.twc.texas.gov
Texas Workforce CommissionVocational Rehabilitation ServicesTravel Premium Plan and Report FORMTEXT ?General Instructions FORMTEXT ? Use this form only for services listed in VR-SFP Chapter 20.10 Travel Premium for mileage FORMTEXT ? and all other travel expenses for one round trip. FORMTEXT ?All requirements in the TWC-VR Standards for Providers must be followed and the most economical means of travel should be used. FORMTEXT ? Service Authorization must be issued for each customer prior to any travel including mileage.Use this form:for reporting mileage only, after travel, which does not required preapproval; FORMTEXT ?for obtaining pre-approval, by a VR Manager for lodging, meals, ground transportation and air travel expenses prior to travel; FORMTEXT ?for reporting actual expenses, after travel, for lodging, meals, ground transportation and air travel expenses. FORMTEXT ?Before traveling, the provider must receive the VR3436 with all required VR Manager approvals for lodging, meals, FORMTEXT ? ground transportation and air travel expenses, a service authorization must be received before any travel, including mileage. FORMTEXT ?Enter information for all customers associated with the round-trip travel. When multiple customers are seen, the total travel cost is FORMTEXT ? divided equally between all customers who were provided service during the round-trip travel. FORMTEXT ? The amount invoiced should match the total in the Summary Report for Invoicing Section and the Actual Travel Expenses sections of the form. FORMTEXT ? Gain signatures prior to submitting the form. FORMTEXT ?Demographic Information FORMTEXT ?Name of Provider: FORMTEXT ?????Name of Provider Staff Traveling: FORMTEXT ?????Beginning and Ending Location of TravelStreet Address: FORMTEXT ?????City/town: FORMTEXT ?????ZIP: FORMTEXT ?????Type of Travel: (select all that apply) FORMTEXT ? FORMCHECKBOX Mileage Reimbursement FORMCHECKBOX Lodging, Meal, Ground Transportation and/or Air TravelServices to be provided to: FORMCHECKBOX Only one customer FORMCHECKBOX Multiple CustomersCustomer Information and Projected Service Hours FORMTEXT ?Summary Report for Invoicing FORMTEXT ?Customer Case IDLocation to be traveled to provide servicesService(s) to be providedProjected Service Hour(s) to be providedActual Number of Service Hour(s) providedTotal Amount to be InvoicedVR Verify HoursVR Staff InitialsCustomer 1 FORMTEXT ?????Street Address: FORMTEXT ?????City/Town: FORMTEXT ????? ZIP: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Customer 2 FORMTEXT ?????Street Address: FORMTEXT ?????City/Town: FORMTEXT ????? ZIP: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Customer 3 FORMTEXT ?????Street Address: FORMTEXT ?????City/Town: FORMTEXT ????? ZIP: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Customer 4 FORMTEXT ?????Street Address: FORMTEXT ?????City/Town: FORMTEXT ????? ZIP: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Customer 5 FORMTEXT ?????Street Address: FORMTEXT ?????City/Town: FORMTEXT ????? ZIP: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Customer 6 FORMTEXT ?????Street Address: FORMTEXT ?????City/Town: FORMTEXT ????? ZIP: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Mileage- NO PRE-APPROVAL REQUIRED FORMTEXT ?Mileage: Requested FORMCHECKBOX Yes FORMCHECKBOX No If yes, answer questions below.Date(s) entered can only be for one round trip. DateStart TimeStarting location Travel to locationNumber of milesVerified by VR StaffVR Staff Initials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Total Round Trip Miles Traveled: FORMTEXT ????? minus 50 miles equals FORMTEXT ????? FORMTEXT ????? miles (carried from line above) divided by FORMTEXT ????? number of customers served in round trip equals FORMTEXT ????? miles FORMTEXT ????? miles (carried from line above) multiplied by approved state rate equals the amount invoiced for each customer FORMTEXT ?????Summary of Travel Expenses Excluding Mileage---MANAGER PRE-APPROVAL REQUIRED FORMTEXT ?Requested Travel Expenses FORMTEXT ?Actual Travel Expenses FORMTEXT ?Anticipated Travel Days: FORMTEXT ?????Actual Travel Days: FORMTEXT ?????Start Date: FORMTEXT ?????End Date: FORMTEXT ?????Start Date: FORMTEXT ?????End Date: FORMTEXT ?????Estimated Total Number of Days Service will be provided: FORMTEXT ?????Total Number of days Services were provided: FORMTEXT ????? Estimated Total Number of Hours of Services to be provided: FORMTEXT ?????Total Number of Hours of Services were provided: FORMTEXT ?????Estimated Total of All Travel Expense: FORMTEXT ?????Actual Total of All Travel Expense: FORMTEXT ?????Lodging FORMTEXT ?Lodging: Requested FORMCHECKBOX Yes FORMCHECKBOX No If yes, answer questions below. FORMTEXT ?Lodging Requested Travel Expenses FORMTEXT ?Lodging Actual Travel Expenses FORMTEXT ? (includes taxes and fees FORMTEXT ?City of LodgingNumber of Nights Per CityEstimated Cost per night per CityTotal Estimated Cost per CityVR Manager ApprovedNumber of Nights per CityTotal Cost Per CityReceipts AttachedVR Verify ExpensesVR Staff Initials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Total Estimated Cost of Lodging Expenses FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoTotal of Actual Lodging Expenses: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Meals FORMTEXT ?Meals Requested: FORMCHECKBOX Yes FORMCHECKBOX No If yes, answer questions below. FORMTEXT ?Meals Requested Travel Expenses FORMTEXT ? Meals Actual Travel Expenses FORMTEXT ?(includes taxes) FORMTEXT ?Meals Based on the GSA’s Federal Domestic Per Diem Rate for CityNumber of DaysTotal Estimated Cost per CityVR Manager ApprovedNumber of DaysTotal Cost per CityReceipts AttachedVR Verify ExpensesVR Staff Initials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Total Estimated Cost of Meal Expenses: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoTotal of Actual Meal Expenses: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Ground Transportation FORMTEXT ?Ground Transportation Requested: FORMCHECKBOX Yes FORMCHECKBOX No If yes, answer questions below. FORMTEXT ?Ground Transportation Requested Travel Expenses FORMTEXT ? Ground Transportation Actual Travel Expenses FORMTEXT ?Type of TravelEstimated Total CostVR Manager ApprovedTotal Cost per Type of TravelReceipts AttachedVR Verify ExpensesVR Staff InitialsBus FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Taxi FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Network Driver (e.g., Uber) FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Other Type of Ground Transportation FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Total Estimated Cost of Ground Transportation Expenses: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoTotal of Actual Ground Transportation Expenses: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Air Travel FORMTEXT ?Air Travel Requested: FORMCHECKBOX Yes FORMCHECKBOX No If yes, answer questions below. FORMTEXT ?Air Travel Requested Travel Expenses FORMTEXT ? Air Travel Actual Travel Expenses FORMTEXT ?Outbound AirportTo AirportEstimated Flight CostVR Manager ApprovedTotal Cost per FlightReceipts AttachedVR Verify ExpensesVR Staff Initials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Total Estimated Cost of Air Travel: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoTotal Actual Air Travel Expenses: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Air Travel Justification:Briefly describe why air travel is necessary and/or how it is the most cost-effective method of travel. FORMTEXT ?????Supplemental documentation for cost comparison attached as addendum FORMCHECKBOX Yes FORMCHECKBOX NoSignatures at Request for Approval of Travel Expenses FORMTEXT ?Provider Signature FORMTEXT ? FORMTEXT ?I, the provider staff person, certify that the expenses requested follow the requirements in the VR Standards for Providers for Travel Reimbursement. FORMTEXT ?Print or type name: FORMTEXT ? FORMTEXT ?????Signature: FORMTEXT ?Date: FORMTEXT ?????VR Manager Signature FORMTEXT ? FORMCHECKBOX Approve FORMCHECKBOX Do not approveI the VR Manager have indicated the approval or disapproval of requested travel expenses above and FORMTEXT ? agree they are necessary for the customer to receive the services outlined in his/her IPE. FORMTEXT ? Print or type name: FORMTEXT ? FORMTEXT ?????Signature: FORMTEXT ?Date: FORMTEXT ?????Signatures at Submission of Actual Travel Expenses I, the provider staff person, certify the following: FORMTEXT ?Each customer received a service other than acquiring a signature, FORMTEXT ?I reported above the actual expenses incurred from the travel following FORMTEXT ? VR-SFP requirements and have attached the receipts as proof of expenses, FORMTEXT ?For any mileage submitted, I used MapQuest Route Planner with shortest distance FORMTEXT ? and round-trip options to identify miles to be reimbursed, FORMTEXT ?For mileage, the first 50 miles driven for round trip are subtracted for total miles driven. FORMTEXT ?Print or type name: FORMTEXT ? FORMTEXT ?????Signature: FORMTEXT ?Date: FORMTEXT ?????VRS Use Only—VRS Approval of the Report FORMTEXT ?Verified preapproval for travel was documented by VR Manager, when applicable. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified the submitted expenses are not greater than the approved amount. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified the report is accurately completed per form instructions, the Standards for Providers, and/or the SA. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified each customer received at least 1 service other than acquiring a signature. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified for mileage that first 50 miles were subtracted from total miles traveled. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified mileage was calculated using MapQuest Route Planner with shortest distance and round-trip options selected. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified that the current state-approved mileage rate was used in calculating the fee for mileage. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified the expenses are split equally between all customers who were provided service within the round-trip travel. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified the receipt for lodging is for a hotel at GSA’s Federal Domestic Per Diem Rate for City traveled to, FORMTEXT ? or a less expensive lodging option is used. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified lodging expenses are equal to or less than the GSA’s Federal Domestic Per Diem Rate for each city listed and receipts submitted. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified meal expenses are equal to or less than the GSA’s Federal Domestic Per Diem Rate for each city listed and receipts submitted. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified ground transportation expenses have a receipt submitted. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified that justification for air travel is appropriate and includes supporting documentation, as applicable. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified air travel expenses have a copy of a complete passenger receipt issued by a commercial airline company FORMTEXT ? or an itinerary issued by the airline company or travel agency with a receipt submitted. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAVerified no gratuity is being invoiced. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf any question above is answered “No,” complete the following: FORMTEXT ? Send a copy of the submitted invoice and the report to the provider with the VR3460 to notify the provider the service delivery or report did not meet the requirements as described in the VR Standards for Providers and/or SA.Date: FORMTEXT ?????Record a case note to document the return of invoice and required form(s). Date: FORMTEXT ?????Report: FORMCHECKBOX Approved FORMCHECKBOX Sent back to providerComment (if any): FORMTEXT ?????Printed name of VR staff member making verification: FORMTEXT ????? Date Verified: FORMTEXT ????? ................
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