DEPARTMENT OF TRANSPORTATION – HUMAN RESOURCES TUITION REIMBURSEMENT REQUEST
Employee Name:	Job Title:	Full Time Part Time* Hrs./Week (*Benefits will be prorated.)
I understand I will be eligible for reimbursement of up to 100% of in-state tuition. Out-of-state and online tuition may be reimbursed at 100% of the rate charged by the University of Nebraska-Lincoln for undergraduate/graduate study after submitting required documentation of course completion and qualified (C or better) grade. I further understand I am responsible for all other costs (matriculation, laboratory, fees, textbooks, supplies, etc.). I understand that if I voluntarily terminate employment within 12 months following the reimbursement for this course, I will be required to repay the Agency a prorated amount in accordance with the Agency policy.
Course Name:	Name of School:
Number of Credit Hours:	Course Number:	Tuition Cost for Course:
Day(s) Of Week Class Meets:	Hours Class Meets:	Date Class Begins:
Declared Program of Study or Degree:	Degree Status: Undergraduate Graduate
Employee's Division/District and Section/Unit:
Employee's Signature:	Date:
When the above information has been completed, the tuition reimbursement request must be submitted to your immediate supervisor/manager. After approval, form will be sent to Human Resources for their review.
Each class requested for tuition reimbursement must be on a separate form.
Approval Responsibilities: Employees should discuss their plans and receive adjusted work schedule approval from their Division Head/District Engineer. If a work adjustment results in an employee working less than full time, the reimbursement amount may be reduced to represent the new FTE Designation. All completed forms shall be sent to Human Resources for Tuition Reimbursement approval. This form must be submitted and approved by Human Resources (HR) BEFORE the first day that class begins.
Supervisor/Manager Comments: Please include any relevant information and/or knowledge you have that would indicate whether or not the employee should receive tuition reimbursement. This includes benefits to the employee and the agency. This also includes a note from the supervisor that the Division Head/District Engineer is aware and approves the work schedule change.
Approved (course is outside of working hours OR if taken within working hours, work schedule is approved) Denied
Supervisor/Manager:	Date:
Received in Human Resources by:	Date:
The employee will submit this form, the Expense Reimbursement Form (177), along with any other required documentation per the expense reimbursement process established in their district/division. Questions regarding tuition payments may be directed to: Ryan Mira, ryan.mira@nebraska.gov

NDOT Form 384, April 2024