Fillable COVID-19 Travel Approval Form (Southern Illinois University-Carbondale)

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COVID-19 Travel Approval Form (Southern Illinois University-Carbondale)

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The COVID-19 Travel Approval Form (Southern Illinois University-Carbondale) form is 2 pages long and contains:

  • 4 signatures
  • 12 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

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Email Address ___________________________
Phone Number __________________________
Conference
□ Workshop
Date
Leaving
Date
Returning
Number of
People Traveling
Number of People
Expected at Event
Travel Type:
car/bus/fly/etc
-
-
COVID-19 Travel Approval Form
□ PrograP
*The University may suspend all travel at any time due to the Covid-19 pandemic and any prior travel authorization may be revoked by the University at any
time.
Please explain why this travel is necessary and consider whether alternate participation is available:
Anyone engaging in any form of travel more than 25 miles from campus is required to complete this form a
minimum of 2 weeks in advance of the proposed first date of travel.
Today’s Date ___________
Your Name _______________________________
Organization/Department ___________________________
□ Other: _______________
Reason for Travel
□ Meeting
□
Location of Event Street
Address
Describe the precautions all travel participants will be required to take (limiting the number of people in
each vehicle/social distancing/wearing face coverings/traveling with hand sanitizer and sanitizing wipes or
spray):
List the names of ALL Travel Participants (including students, advisors, faculty and staff):
□ Yes
□ No
*Please note that this form does not confirm space. Space must be arranged with the appropriate facility based on approval of the event.
During this time, SIU Carbondale is exercising the utmost caution to ensure the health and well-being of our students,
faculty, staff and community members. Please answer the following questions as to how you will take precautions to ensure
the safety of travel participants. Please reference the Restore Illinois Meeting and Social Event Guidelines for assistance by
visiting: https://dceocovid19resources.com/restore-illinois/restore-illinois-phase-4/meetings-and-social-events/.
Will you require face coverings? This is a mandatory requirement.
Will you ask all travel participants if they are exhibiting COVID 19 symptoms?
□ Yes
□ No
Please visit the Restore Illinois Meeting and Event Guidelines Checklist for Wellness Screenings for questions to ask: https://
dceocovid19resources.com/assets/Restore-Illinois/checklists4/AllChecklists.pdf.
What measures will you take to ensure proper cleaning and sanitizing procedures are in place at your travel
destination? What precautions will be taken by the event organizers while you are participating in the event?
How will you ensure your travel participants adhere to social distancing guidelines during travel and all
events? Please note considerations for limiting congregation of people and movement of people during the
event. All participants MUST wear a mask while traveling in a vehicle.
Please provide any additional event details we need to know:
____________________________________________
Travel Sponsor Signature/Date
____________________________________________
Dean/Director/Date
____________________________________________
Vice Chancellor or Provost Signature/Date
(Recommended to proceed)
____________________________________________
Chief of Police Signature/Date
(Recommended to proceed)
□ By checking this box, travel sponsor agrees to keep an accurate record of travel attendees and will provide
this list, to appropriate campus personnel
Do you have appropriate PPE in place to travel to the event?
□ Yes
PPE refers to personal protective equipment and includes masks, hand sanitizer and sanitizing wipes or spray.
□ No
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COVID-19 Travel Approval Form (Southern Illinois University-Carbondale)

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Completed 24 July 2020

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