Texas Tech University Health Sciences Center
Foreign Travel | Pre-Approval Form
As required by TTUHSC OP 79.04
Date: _________________
Name of traveler: ___________________________________________________________________________
Department: ___________________________________________________________________________
Destination city: _______________________ Destination country: __________________________
Departure date: _______________________ Return date: __________________________
Funding source*: _______________________ Estimated Cost: __________________________
*Not allowed on state appropriated funds.
Purpose:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
☐ Check if travel will include work in a clinical setting**
☐ Check if you will be accompanied by TTUHSC students
Justification / Benefit:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Approvals:
☐ Not Approved
__________________________________________________________________________ ☐ Approved
1
st
Level Approver / Dept. Head / Reg. Dean Signature Date
☐ Not Approved
__________________________________________________________________________ ☐ Approved
2
nd
Level Approver / Dept. Chair / A.V.P. / Dean Signature Date
☐ Not Approved
Tedd L. Mitchell, MD ☐
Approved
President Signature Date
**Before departing, the traveler must contact the Office of Global Health regarding exposure management procedures while
abroad. In the event of an exposure to blood borne pathogens while abroad, any costs for post-exposure treatment, including
lab testing and antiviral medications, will be the responsibility of the department/school to which the employee is assigned.
