Fillable NASA COVID-19 Travel Exception Form

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NASA COVID-19 Travel Exception Form

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National Aeronautics and Space Administration
REQUEST FOR TRAVEL EXCEPTION FORM – COVID-19
03/26/20 Version
After review and concurrence from Center Director/OIC, please
submit to: nestor.a.tezna@nasa.gov
Submission
Date:
NASA Traveler Information
Traveler
Name:
Center: TDY
Location:
Program/Office: Trip Dates:
Activity
Travel/
Conference
Name:
Project/Activity
Background
Description:
Project/ Activity
Funding
Source(s):
(e.g., mission
directorate(s),
reimbursable, other)
Resources
Required
to
Continue
During
Travel:
Access to Center (generally)
Access to NASA Facility:
Other:
Center Director
(OIC)
Exceptions may be granted for travel that falls into one of two categories:
1. Mission Critical Work
• The travel must be necessary to continue mission/project critical work that cannot be performed
remotely/virtually.
• The work must be performed to maintain mission/project critical operations or schedules.
-or -
2. Protection of Life or Property
• There must be a reasonable and articulable connection between the function to be performed,
physically onsite, and the safety of human life or the protection of property, and
• There must be a reasonable likelihood that the safety of human life or the protection of property
would be compromised, in some significant degree, by delay in the performance of the function
in question.
FTE
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National Aeronautics and Space Administration
REQUEST FOR TRAVEL EXCEPTION FORM – COVID-19
2
Please identify and describe the human life, property, or mission impact that
would be threatened were the travel to be halted:
Please identify the function that requires the person(s) to travel:
Is there any other information you think relevant to this request?
EXECUTIVE COMMITTEE DETERMINATION
Determination by NASA EXECUTIVE COMMITTEE
Decision:
Date:
Name:
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signature
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As Administrator Jim Bridenstine said in his statement yesterday, our people are our greatest asset. As
such, we are reminding you of the potential risks with travel during this current public health
emergency.
The Centers for Disease Control and Prevention has determined that some people are at higher risk of
getting very ill from the COVID-19 virus, especially while traveling. This includes:
• Older adults (aged 65 and over)
• People who have serious underlying health conditions
o Heart Disease
o Diabetes
o Lung Disease (Asthma, emphysema)
o Chronic disease (HIV, Hepatitis C, Multiple Sclerosis, etc.)
o Those on immune lowering medications for chronic disease (rheumatoid arthritis,
Multiple Sclerosis, Scleroderma, etc)
In addition, much is unknown regarding the risk of this virus in pregnancy or those currently breast-
feeding.
If you or your primary care physician believe your personal health risk may fit into one of the above
categories, or that you have additional risk factors not mentioned here, please advise your supervisor
that you believe you are in a higher risk category and do not wish to travel.
In addition, guidance on official travel and travel risk from the White House is listed at the link below.
https://www.whitehouse.gov/wp-content/uploads/2020/03/M-20-14-travel-guidance-OMB-1.pdf
For those who are currently on travel and are having COVID-19 symptoms: Follow the CDC Guidance and Do Not
Travel. Shelter in place and self-quaratine where you are. Please contact your personal medical pro
vider for guidance.
You may also want to reach out to local medical authorities or the U.S. Embassy if overseas and you believe you need
medical attention. The NASA contracted medevac providers can also direct you to the closest most appropriate medical
facilities nearest you, should you require assistance.
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NASA COVID-19 Travel Exception Form

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Completed 26 March 2020

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