Rev. 2/19
Louisiana State University
Office of Accounting Services
Accounts Payable & Travel
217 Thomas Boyd Hall
REQUEST TO TRAVEL TO RESTRICTED REGIONS FOR INDIVIDUAL TRAVELERS AS295
Instructions: At least 30 days in advance of the proposed travel, please complete all pages of this form (attaching
additional pages, if necessary), obtain the required signatures on page 1, send to the International Travel
Oversight Committee (ITOC) in care of Director of Accounts Payable & Travel (217 Thomas Boyd Hall
or pgremill@lsu.edu), and the final approved version must be attached to the Spend Authorization in Workday.
Traveler Details
Name: LSUID: E-Mail
: ___________
Title: Phone: _________________
Department: Department Mailing Address: _
Business Manager: E-Mail: ___ _
Description of Travel
Purpose of Proposed Travel:
Location (list all countries and citiesbe specific):
Travel Advisory of Restricted Region (circle one): LEVEL 3 4
Exact Dates of Proposed Travel:
Required Signatures
Traveler Name (please print): _
Traveler Signature:
Date:
_
Director/Dept. Head/Chair Signature: Date:
Dean Signature: Date:
ITOC: __________ Recommends approval ___________ Does not recommend approval
Associate Vice President: _____________________________________ Date: ___________________________
________ Approved ________ Denied VP for Academic Affairs: ____________________________________
Rev. 2/19
Traveler’s E
mergency Contact Information While Abroad
Please provide the appropriate information that Louisiana State University and/or outside sources may use to
communicate with you in the event of a crisis:
Traveler name as it appears on Passport:
Passport Number: Expiration Date:
Phone number(s) where traveler can be reached internationally:
Physical Address of all accommodations while abroad:
Alternate Emergency Contact Information While Abroad
Please provide an alternate person that Louisiana State University and/or outside sources may use to
communicate with you in the event of a crisis:
Name: Relation to Traveler:
Phone Numbers (cell/work/home):
E-mail:
Physical Address:
Department Emergency Contact Information
Please provide departmental contacts for the University to work with in the event of a crisis:
Name & Title: Department:
Phone Numbers (cell/work/home):
E-mail:
Secondary Contact Person: Phone:
Rev. 2/19
OTHER TRAVELERS
Please provide the names of any other travelers or individuals you will be working with during the trip:
Name:
_Phone_
_ Affiliation
Name:
_Phone
_ Affiliation
Name:
_Phone_
Affiliation
Name:
_Phone_
Affiliation
Name:
_Phone_
Affiliation
ITINERARY
Please provide a complete itinerary of your travel, including all departure/arrival dates, airline flight #’s,
locations, and modes of transportation.
Rev. 2/19
SAFETY & SECURITY A
SSESSMENT
1. The US Department of State website is www.travel.state.gov and lists country-specific Travel Advisories
for US citizens. Please summarize (do not copy/paste) the current State Department Travel Advisory
for your location.
With regard to current US Department of State Travel Advisory and your own
health/safety/security assessment of the proposed location, what risks might you encounter while
traveling?
2. What specific steps will you take to mitigate these risks? What is your emergency plan as it relates to
natural disasters, civil/political unrest, and medical emergency related to accident or injury? Please be
as specific and detailed as possible.
3. De
scribe your level of familiarity with the proposed location. Include professional connections, family
living there, language abilities, familiarity with culture, experience visiting/living/working there, etc.
Necessity of Travel:
1. Why must the travel take place at the proposed location?
2. Co
uld you engage in a similar or alternate program in a different location?
3. How is t
he travel critical to the mission of the University?
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