Learning Support Fund (LSF) - Travel and Dual

Accommodation Expenses (TDAE) claim form

Our guidance booklet ‘Completing your TDAE claim’ is available if you need any information when
completing this form. Completed forms should be returned to your university along with your student cover
sheet.

If this is the first time you are applying for any of the Learning Support Fund allowances, you must include a copy of
your Student Finance letter for the academic year you are claiming for as part of your evidence.

If you are not in receipt of a student loan, contact us on 0300 330 0521 and you will be sent a short form to
complete. This will be used to determine whether you are eligible for LSF.

All TDAE claims must be received by Student Services within nine months of the date of the last day of the
practice placement for which you are claiming. You must complete all sections of the form or your claim may be
delayed.

1. Personal Details - you must complete this section in full.

LSF account L S F
University student reference/ID number

Surname

Forename(s)

Date of birth / /

Term-time address

Postcode

Mobile number

Email address

Have you been authorised to receive a travel allowance through Student Loans Yes No
Disabled Students Allowances towards your placement travel costs?

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2. Your course and study base

Name of university

Name of course

Course year

Full address of your normal

place of study.

Postcode

3. Travel to your normal place of study

How do you normally travel to the above location? A. Walk

If your method of travel varies, you should select the
option which applies to you the majority of the time. B. Receive a lift from someone else

C. Public transport
Tick one box only.
D. Drive (own vehicle) / car share

E. Cycle

If you ticked C (public transport)

State the total daily return cost £
or
If you use a travel pass or season ticket, give the total cost and tick whether this is weekly/monthly/annually.

£ weekly monthly annually

If you ticked D (drive own vehicle / car share) or E (cycle)

What is your normal return mileage per day?

If you usually incur parking, tunnel or toll road costs, give the total daily cost of these £

Information
If you are able to claim any reimbursement for the cost of the above travel directly from your university, you
must still provide details of the full cost of your actual travel (before reimbursement) as requested above.

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4. Details of your practice placement

Do you receive any financial help from your university towards your Yes No
placement travel costs?

If yes, how much have you been given or how much do you expect to £
receive during the academic year?

FULL address of your practice placement site

(If you were based at more than one site,
please detail on a separate sheet)

Postcode

If you used public transport to travel to placement please indicate the cost of your
daily return journey.

If you drove or cycled to placement please indicate the daily return mileage.

If you use/used a travel pass or season ticket please state the total cost of this
and whether this was weekly, monthly etc.
Car hire
Cost to you of hiring the car (you must provide evidence):

Remember to include the appropriate receipts to enable your university to check your claim.

Overseas placement - other costs

If your placement took place outside the UK, the Channel Islands or the Isle of Man, you may be entitled to
reimbursement for essential associated costs as detailed below.

If applicable, enter details of the costs below and provide evidence with your claim form.

Essential vaccinations/medication/tests £

Medical insurance £

Visa(s) £

You should detail any travel and accommodation costs at sections 5 and 6 of this claim form.

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5. Details of claim - you must complete this section in FULL (please print as many pages as required)

Provide details of each daily return journey to placement. If you are claiming for more than 20 journeys
for this placement period you should print off and complete additional copies of this page, as required.

Total daily mileage

including mileage
Date Journeys Public transport Other travel
undertaken if you used a
hire car

Return daily Means of

Postcode Postcode Community Cost of Tunnels, toll roads
mileage to transport
from to mileage transport and car parking
placement site (bus, train)

10

11

12

13

14

15

16

17

18

19

20

TOTALS

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6. Dual accommodation costs

If you had to take temporary secondary accommodation away from your normal term time address in order to
attend your practice placement, and you incurred additional costs as a result, complete this section.

You cannot claim reimbursement if you stayed in the parental home in order to attend your
placement. If this is the case do not complete this page and go to Section 7.

Full address of your placement accommodation

This cannot be your normal term time address.

Postcode

Period claiming for:

From /
/ to / /

Total cost (to you) of your placement accommodation for this period. £
You must include official evidence with your claim form.

Do you live with your parents during term time? Yes Go to Section No
7

If No, state the approximate cost of your normal term time £

accommodation during the above dates

You do not need to provide evidence of your term time address costs but in some cases we may need to contact
you for further information.

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7. Summary of claim - you must complete this section in full.

Use this section to summarise the details of your travel costs using the information you have entered at Sections 5
and 6.

Private mileage to and from placement

Total number of
miles, including
Mode of transport community mileage Mileage rate Total amount

Bicycle x 20 pence =

Motor vehicle x 28 pence =

Total mileage costs £

+
Total public transport costs £
+
Other travel costs, (car parking, car hire, tunnel charges, road tolls) £
=
Total cost of your placement travel this claim £

minus
Total cost of your normal travel to/from university £
This is the total return cost of your daily travel to university (section 3) multiplied by the total number of
days on placement (section 5). Please refer to the mileage rates above to calculate the cost.
=

To work out the total amount of travel costs you can claim, deduct your total
£
daily travel to university from the total cost of all your placement travel.

Overseas placement -other allowable costs (vaccinations, visas , medical insurance) £

Placement accommodation costs

£
Enter the amount for your placement accommodation costs if applicable.

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8. Student’s declaration - You must read, sign and date this section in all cases

Please review all information you have provided before completing this declaration. Read this declaration carefully
before accepting it. If you choose not to accept it, your funding application will not be processed.

I declare that:

a) I am undertaking a pre-registration programme at a university in England that is eligible for Travel and Dual
Accommodation Expenses.
b) I have read and understood the relevant booklet/s and/or any other other information regarding the
conditions for claiming Travel and Dual Accommodation Expenses.
c) I confirm that I am in receipt of a tuition fee and maintenance loan from the Student Loans Company.
OR
I confirm that I am not in receipt of a student loan for personal reasons and I have provided the required
eligibility evidence and/or additional declaration as specified by NHS Business Services Authority.
d) I confirm that I am studying at a higher education institution in England.
e) I confirm that I have enrolled and commenced on my programme of study and am thus in active training.
f) I confirm that the expenses claimed were essentially incurred as a result of my attending practice placements
and that my normal daily travel to university costs have been deducted.
g) I confirm that I have used the cheapest available transport to access the practice placement/s.
h) I confirm that, if I have claimed for a private motor vehicle, I have appropriate insurance in place.

i) Student Services is committed to administering entitlement accurately wherever possible. I agree to pay back
Student Services within 30 days of receiving notification any excess payment, fees and any other charges, in
the event of the following circumstances:
• Changing my study pattern from full-time to part-time
• Withdrawing, abandoning, suspending, deferring or interrupting the course permanently or temporarily for
any reason, regardless of whether I intend to return
• Taking a year out from study
• Being overpaid because I have failed to notify NHSBSA Student Services of a change in my circumstances.
• Where Student Services at its absolute discretion determines I have been given financial support to which I
am not entitled
• Gaining support from sources other than Student Loans Company that might affect my entitlement
Should I fail to make full repayment of any amount due or agree an acceptable repayment plan with NHSBSA,
I understand that the debt may be passed to a debt collection agency. I also understand that I may be charged
for any additional recovery costs and/or interest at the rate of 8% on the referred debt which may be added to
the balance.
j) I consent to the disclosure of information on this form on the following understanding:

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Student Services privacy notice

The NHS Business Services Authority (NHSBSA) is responsible for this service.

Why we process your information

We will use the information you provide to:

• assess your application

• pay you
• detect and prevent fraud and mistakes
• help plan and make improvements to NHS services, and/or direct patient care

By law, we must process this information on behalf of the Department of Health and Social Care (DHSC).

Sharing your personal information

To prevent, detect and investigate fraud and errors, we may share your information with:

• Student Loans Company

• HM Revenue and Customs
• higher education institutions
• the Home Office
• organisations from which you receive benefits, bursaries, grants or support
• bodies performing functions on behalf of the above organisations

We may share information with the DHSC to investigate and prosecute fraud, or any other unlawful activity affecting
the NHS.

We may share information with the Cabinet Office in relation to the National Fraud Initiative.

Anonymised information may also be shared with the DHSC to monitor compliance with equality law.

Information that identifies you will not be transferred outside the European Economic Area.

Keeping your personal information

We will delete your data no later than seven years after your course finishes.
 
Your rights

The information you provided will be managed as required by Data Protection law.

You have the right to:

• receive a copy of the information the NHSBSA hold about you

• request your information be changed if you believe it was not correct at the time you provided it

From 25 May 2018, you have the right to:

• request that your information be deleted if you believe we are keeping it for longer than necessary

Find out more about your rights and how we process information.

I understand that the administration of Travel and Dual Accommodation Expenses and responsibility for counter fraud
and security management in the NHS are both responsibilities of the NHS Business Services Authority. I understand

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 that NHSBSA Student Services may share the information on this form with NHS Counter Fraud Authority for the
purposes of the prevention, detection, investigation and prosecution of fraud or any other unlawful activity affecting
the NHS.

I understand and accept that if I fail to give sufficient notice of any change to my bank or building society
account details, or provide incorrect details, NHSBSA Student Services cannot take responsibility for
payments made to an incorrect account, delayed payments or non-payment of the funding.

I understand and accept that the terms and conditions (including rates) of Travel and Dual Accommodation Expenses
may change at any time without notice, and the scheme is subject to continued government funding, which may
cease at any time without notice.

I declare that the information given on this form and in any supporting documents provided is complete and
accurate. I understand and accept that if I provide NHSBSA Student Services with false or misleading information,
financial support may be refused or withdrawn and I may be liable to prosecution and/or civil proceedings.

Any future amendments to this application will require you to re-accept this declaration.

Signature Date / /

You are advised to make a copy of your form and any receipts or invoices before handing your claim to your university
for authorisation.

Remember to include a copy of your LSF student coversheet with this claim.

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9. University authorisation

Checklist
Has the student completed ALL the relevant sections Yes No Return form to student
and signed and dated the declaration?

Has the student provided you with an LSF student coversheet? Yes No Return form to student

Has the student submitted travel and/or accommodation receipts, Yes No Return form to student -
where applicable? no expenses can be paid

Has the student submitted this form to you within 9 months Return form to student -
of the final date of the placement period for which they are Yes No
no expenses can be paid
claiming?

Declaration
In countersigning this claim for Travel and Dual Accommodation Expenses, I confirm the following:

• The student named at Section 1 of this form is studying on a pre-registration healthcare programme that is, to the
best of my knowledge, eligible for Travel and Dual Accommodation Expenses.
• The practice placement/s for which the student is claiming the Travel and Dual Accommodation Expenses were
essentially incurred as part of the overall programme requirements.
• the expenses detailed in this claim form have been reasonably and necessarily incurred in accordance with the
provisions of the policy.
• The student’s normal daily travel to university costs have been deducted.
• I have checked the claim and, to the best of my knowledge, confirm that the expenses being claimed are correct.
• I have checked the receipts where applicable.
• The receipts will be retained in line with this institutions audit and governance requirements.
• I am a registered employee of the higher education institution that the student attends, and I have authority
agreed by the higher education institution to countersign Travel and Dual Accommodation Expense claims.
• I understand and accept that if I provide false or misleading information, I may be liable to prosecution and/or civil
proceedings.
• I understand that the administration of Travel and Dual Accommodation Expenses and responsibility for counter
fraud and security management are both responsibilities of the NHS Business Services Authority.
• I understand that Student Services may share the information on this form with NHS Counter Fraud Authority for
the purposes of the prevention, detection, investigation and prosecution of fraud or any other unlawful activity
affecting the NHS.

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 Signature

Date / /

Email address

Print name

Position held

University official stamp

Universities must send completed forms to Learning Support Fund (TDAE), Student Services, Ridgway
House, Northgate Close, Middlebrook, Horwich, Bolton, BL6 6PQ.

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