Department of Health
Travel Voucher Form
State Employee
Non-State Employee
Instructions & Help
Mileage Map
First Name
Last Name
Employee Number
Advance
Expense
License Plate No.
Home Station
Subtotals
Purpose of Travel:
GRAND TOTAL
Apply To Advance
AMOUNT REIMBURSABLE
Date
Description of Travel
(Please include the name of every town visited)
Time
Auto
Miles
Trans
Cost
Meals
Lodging
Miscellaneous
Expense
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
From:
To:
Misc:
Leave:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
NC
OC
NC
Meals - Only Claiming(OC)
Breakfast
Lunch
Dinner
OK
Close
Trip Options
Was this an In-State or Out-of-State Trip?
In-State Trip
Out-Of-State Trip
Did you Fly?
Yes
No
If you drove a vehicle on your trip please select:
State Car
Private Car
Low Miles
High Miles
License Plate No.
OK
Close