Fillable Request to Travel to Restricted Regions for Faculty/Staff (University of Texas at Arlington)

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Request to Travel to Restricted Regions for Faculty/Staff (University of Texas at Arlington)

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The University of Texas at Arlington
University International Oversight Committee
Request to Travel to Restricted Regions for Faculty/Staff Travelers
Title
Email
Phone
UTEID
Name
Department
Instructions: Please complete all pages of this form (attaching additional pages, if necessary) and bring to the appropriate administrators
for signatures. Submit all documentation to the International Oversight Committee (IOC) at least 4 weeks in advance of proposed
travel. You can fax to 817-272-5005 or scan and e-mail all required materials to Jay Horn at the Office of International Education at
horn@uta.edu.(Emailed submissions preferred).
Traveler Details
Description of Program & Travel
Required Signatures
Purpose of Proposed Travel
Location (Country and Cities - Be specific)
Exact Dates of Proposed Travel
Traveler Signature
Date
Date
Academic Chair Signature
Date
Dean Signature
Email
Name
Email
Phone
Department
Name
Phone
Department
Page 1 of 5
The University of Texas at Arlington
University International Oversight Committee
Request to Travel to Restricted Regions for Faculty/Staff Travelers
Traveler's Emergency Contact Information While Abroad
Please provide the appropriate information that UTA and/or outside sources may use to communicate with you in the event of a crisis:
Traveler name as it appears on Passport
Phone number(s) where traveler can be reached internationally
Physical Address of all accommodations while abroad
US Emergency Contact Information While Abroad
Please provide information for your chosen contact person to use in the event of an emergency or crisis:
Physical Address
Email
Relation to Traveler
Name
Phone Numbers (cell/work/home)
UTA Departmental Contact
Please provide a departmental contact for UTA to work with in the event of a crisis
Name and Title
Email
Department
Phone Numbers (cell/work/home)
Secondary Contact Person
Phone
Page 2 of 5
Host Institution Contact (if applicable)
Please provide contact information for your primary contact at the host institution
Name and Title
Email
Department
Phone Numbers (cell/work/home)
The University of Texas at Arlington
University International Oversight Committee
Request to Travel to Restricted Regions for Faculty/Staff Travelers
ITINERARY
Please provide a complete itinerary of your travel, including all departure/arrival dates, airline flight #'s, location and modes of transportation
Page 3 of 5
The University of Texas at Arlington
University International Oversight Committee
Request to Travel to Restricted Regions for Faculty/Staff Travelers
In the space provided below, please include a statement clearly describing the following:
1. The purpose of proposed travel
2. Why this travel must take place in the proposed location
3. Why you cannot engage in either a similar/alternate program in a different location
Explanation of Travel
Page 4 of 5
The University of Texas at Arlington
University International Oversight Committee
Request to Travel to Restricted Regions for Faculty/Staff Travelers
Page 5 of 5
1. International SOS is UT System's international emergency assistance provider. The website is www.internationalsos.com, and the
UT membership ID is 11BSGC000037. Enter the membership number ID to access the country-specific medical and safety information
that this site provides. According to International SOS, what is the overall "Country Travel Risk Rating"?
Safety and Security Assessment
Insignificant
Low
Medium High
Extreme
2. The US State Department website is www.travel.state.gov and lists country-specific Travel Warnings and Alerts for US citizens. With
regard to current State Department Travel Warning or Alert and your own health/safety/security assessment of the proposed location,
what risks might you encounter while traveling?
3. Describe your level of familiarity with the proposed international location.
Include professional connections, family living there,
language abilities, familiarity with culture, experience visiting/living/working there, etc.
4. What specific steps will you take to mitigate these risks. Please be as specific as possible.
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Request to Travel to Restricted Regions for FacultyStaff (University of Texas at Arlington)

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Completed 30 August 2020

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