Department of Rehabilitation Sciences – Master in Physiotherapy

Travelling Allowance Reimbursement Form for Clinical Placement

Name of the student: ___________________________ Student No: ___________________________
Clinical Placement site: ________________________________________________ Block: CE IV/ V/ VI
Period: _____________________________________ to ______________________________________
Eligibility:
1. Travel from the clinical setting to client’s home/community settings for 3 or more days per week was required;
2. Expense on public transportation, e.g. bus, mini-bus, LRT, MTR was incurred.
3. A claimant who knowingly gives false information or withholds any material information renders himself/herself liable to refund of any or
all payments rendered and/or to disciplinary proceeding.
4. The information a claimant provides in this form will be used to facilitate the process of his/her claim or a directly-related purpose in the
University.  It may be provided to departments/offices/centres/units, and/or any other internal/external bodies, where applicable,
authorized to process the information for purposes relating to the collection of such information.

Please submit the reimbursement form within 3 weeks after completion of the clinical placement block.

Brief description of Mean of

Date Time From To Travelling Fee
activity involved: Transport

Signature of applicant: ___________________________________

Acknowledgement of Clinical Educator: _____________________

Signature of MPT Faculty in-charge of the placement arrangement:: __________________

 Payment will be made directly into the Student’s bank account. Please complete the bank details at
https://www40.polyu.edu.hk/fosae/.

PLEASE FORWARD TO General Office QT512 (RS) FOR PROCESSING.

RS(July2021)