Office of the Provost and EVP Research

Application for Exemption from Travel Restrictions
To Countries Under a U.S. Department of State Travel Warning

Effective April 22, 2010, The University of Texas System announced the suspension of travel to restricted countries, including those on the U.S. Department of State Travel Warning List.

UTHealth is committed to the safety and well-being of its students, faculty and staff.  However, the University also recognizes the importance of international travel and global programs to its academic mission.  UTHealth may grant exemptions from the University’s current travel restrictions for carefully planned trips.  

If, after reviewing the U.S. Travel Warning, you still wish to travel to a restricted country for University-related business and/or with a University-sponsored program, you must complete and submit this application.  In order to receive an exemption, you must demonstrate your awareness of the risks you face during your travel, your familiarity with the destination, the presence of a local support network to assist you if needed and careful planning about where you will stay and work.  Your application will be reviewed by the President’s Advisory Panel on International Travel.  Please provide detailed descriptions in your answers to demonstrate to the Panel your readiness for travel in countries with significant health or safety concerns.

Important Notice: If you are completing this form off-campus, you must be connected to the UTHealth VPN before submitting your application. Log in at vpn.uth.tmc.edu before completing this form.



Primary Traveler Information
Note: All Highlighted fields are required

Last Name as it appears on Passport Required
First Name as it appears on Passport Required
Middle Name as it appears on Passport

Position Title

Institutional Email Address
RequiredInvalid format.

Office Phone Required

School  

Department / Divison
Required

Full Name of your Department Chair
or Division Director
Required
Has he/she been informed of your travel?  

Please make a selection.
 

Travel Details
Anticipated Travel Dates: From RequiredInvalid format. to RequiredInvalid format.

Indicate Your International Travel Destination (Restricted Country)
Required
City Required State

 

Please Describe the Purpose and the importance of your Travel as well as its relevance to UTHealth (e.g., please specify if your travel is related to a sponsored project and/or a UTHealth affiliated program)



Contact Information at Destination

Hotel / Residence (Provide name, address, phone number)
Required

Place(s) of work (Provide name, address, phone number)
Required

Local Contact Person (Provide full name, professional title, affiliation,
phone number(s) and email address)
RequiredRequired


Travel Safety

Please describe all precautionary measures taken to ensure your safety and health while traveling. (See U.S. Department of State Guidance Website). Include specific information related to the local threat level, and the measures that will be in place to assure your safety
Required
Required Required

Please describe your familiarity with the region (prior experience visiting/living/working there, local language ability, etc)

Required

Please describe the local support network that will be available to you including security, transportation, hosts, and any related information
Required


Please detail any special considerations relating to your request for exemption:


Emergency Contact Information While Abroad


Please provide a departmental contact for UTHealth to work with in the event of a crisis:

Full Name of Primary Contact
RequiredProfessional Title
Required
Department / Division

Required
Phone Numbers (cell / work / home)
Required
Email Address
Required


Full Name of Secondary Contact

RequiredRelationship to You

Department / Division

Required
Phone Numbers (cell / work / home)
Required
Email Address
Required


U.S. Embassy
Please provide information on the U.S. Embassy at your destination (information can be found in the U.S. Travel Warning)

Embassy Address

Phone number

Webpage

You are encouraged to register with the U.S. Embassy through the State Department’s travel registration web site. By registering, U.S. citizens make it easier for the Embassy to contact them in case of emergency. Note: if you are not a U.S. citizen, you are encouraged to look into registering with the Embassy of your citizenship.


Additional Travelers
Please list all other UTHealth Faculty, Staff or Students participating in the trip. Include the full name, School / Department and their classification (Faculty, Staff, Student):


Acknowledgements

I certify that I will register with International SOS either by booking travel with UTHealth's contracted agency, Corporate Travel Planners, or by manually enrolling in International SOS prior to my departure.
Please make a selection.
Please make a selection.

Please make a selection.

Reminder: If you are completing this form off-campus, you must be connected to the UTHealth VPN before submitting your application. Log in at vpn.uth.tmc.edu before submitting this form.

Questions? Please contact the Office of Global Health Initiatives at (713) 500-3559.

 

University of Texas Houston Health Science Center