Travel Waiver Request Form

Travel Waiver Request Form

Instructions

This form is for travelers who are planning trips to destinations with State Department Advisories of level 3 or 4, or CDC Travel Warning level 3. For faculty and staff whose travel does not fall in these advisory levels, a Concur travel request may be submitted directly and this form is not required. All students should work with the Education Abroad office regarding travel approval and international insurance.

Please complete this form in detail, addressing each point. Incomplete applications will be referred back to the traveler for additional clarification or denied based on insufficient information. Include pertinent sources or links in the fields below. You may email any supplementary documents to Emily Hassenstab at ehassenstab@unomaha.edu after submitting this request (letter of invitation or sponsorship, schedules, emails from hosting organization, etc.). Travelers who wish to undertake university sponsored international travel must complete this petition questionnaire prior to travel. The goal of this enhanced procedure is to promote decisions and practices that can mitigate heath and safety concerns, as well as the traveler’s exposure to COVID-19. This form serves as part of the approval process for UNO compliance with the NU System's Executive Memorandum 25 policy.

The traveler understands that the university may be limited in its ability to provide assistance and resources in the event of a crisis, including the possibility of being delayed in the host country due to newly imposed travel restrictions or a positive COVID-19 diagnosis.

The university retains the right to withdraw approval and/or require the traveler to leave a high-risk location at any time.

Traveler Information

Traveler Name (First Last)*

Preferred Email Address*

Preferred Phone Number*

University Affiliation*

Select or enter value

Department/Unit

College (if applicable)

Supervisor

Travel Approver

Study Abroad Program/Provider & University (if applicable)

International Destination(s) (city/country)*

Departure Date*

If departure date is tentative, please enter the earliest date that you would depart.

Return Date*

Describe your role at the university, and how your proposed travel relates to that role, including prior familiarity with your destination.

Explain, in detail, what is the purpose of this trip? Is there an on-site host, institution, or other supporting organization? If so, how will they be supporting you while abroad?

Why is this proposed trip essential travel? Why is this trip critical to your role, unit, or studies?

Can the trip be postponed? Can it be conducted remotely?

Travel Preparation

Have you confirmed with your on-site host or institution that you will be able to conduct your activities as planned?

Yes

N/A

Are there any modifications to your activities or studies?

Ex. Online classes, modified visits or meetings, alterations in programming, ...

I have reviewed the following resources concerning my travel destination during the planning stages. I will continue to review these resources up to my departure and while abroad.*

CDC Guidance: Before and After International Travel https://www.cdc.gov/coronavirus/2019-ncov/travelers/international-travel-during-covid19.html
CDC Travel Health Notices map and destination-specific guidance https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html
DOS Travel Advisories https://travel.state.gov/content/travel/en/traveladvisories/traveladvisories.html/
Review the U.S. Embassy’s web page for your destination country linked in the Travel Advisory
International Airport Transport Association (IATA TravelCentre) https://www.iatatravelcentre.com/#

Yes

What is the U.S. DOS Travel Advisory Level rating for your destination?*

DOS Travel Advisory Levels: https://travel.state.gov/content/travel/en/traveladvisories/traveladvisories.html/

Level 1: Exercise Normal Precautions

Level 2: Exercise Increased Caution

Level 3: Reconsider Travel

Level 4: Do Not Travel

What is the CDC Alert Level for your destination?*

CDC Travel Destinations: https://wwwnc.cdc.gov/travel/destinations/list

Alert Level 1

Alert Level 2

Alert Level 3

Highlight your understanding of the health and safety materials you have read in preparation for your proposed travel, and address the concerns raised by the USDOS, CDC travel advisories, and other sources as pertinent.

List specific actions you will take to be an active participant in your own health and safety while abroad.

Travel Logistics

Describe your travel logistics in detail.

From which country are you departing? Will you be traveling through any other countries prior to entering your destination? What modes of transportation will you be utilizing?

Is your destination currently accepting visitors originating from the US and/or the country you are traveling through?

Yes

Describe any visa requirements for your destination.

Additionally, are there COVID-related entry requirements for your destination or points of entry prior to your primary destination?

Describe your accommodations for the duration of your travel.

What COVID precautions are in place? Would you be able to quarantine in this location if needed? What amenities are located on-site (wi-fi, food service, etc.)?

If there is a sudden change in conditions (security or health changes) and international borders suddenly close, what arrangements would you make? Include who you would notify and their contact information in the event of your delayed return.

Health Care

Where is the nearest hospital or clinic where you can receive medical care, if needed?

Please describe any additional challenges with the health care system in your destination country if that is mentioned in the State Department or CDC Advisories and how you would handle emergency care.

Will you enroll with UNO’s international insurance plan (provided by AIG) and review the policy including usage instructions, prior to departure?

Approved travelers will be provided with the AIG NU policy number and login information. Faculty and staff travelers with personal travel attached to travel for business must purchase additional insurance for those days, and for any companion travelers. Personal/Companion international travel insurance can be purchased here: https://commerce.cashnet.com/cashnetg/static/storefront/unocw/catalog/INTTRAVINS

Faculty and staff AIG policy info can be found here: https://nebraska.edu/travel/international-travel/aig-travel-protector-insurance

Student travelers will need to purchase AIG insurance through the Education Abroad office.

AIG Travel Assistance Portal: https://travelguard.secure.force.com/TravelAssistance/TGPreLoginHomePage?PL=AIGACCIDENTANDHEALTH

Yes

Will you enroll with UNO’s international insurance plan provided by AIG, international insurance provided by ISEP, or your affiliate provider and review the policy including usage instructions, prior to departure?

Please inquire with the Education Abroad office if you have questions about which insurance policy you will have while abroad.

Select or enter value

Self-quarantine/Isolation

Will a self-quarantine period be required upon arrival?

Yes

If so, what are the quarantine arrangements and additional costs associated with housing and meals?

Are you prepared to isolate for 10 days (or more) and care for yourself in your destination if you become ill with COVID, or have been exposed to a contact that has been diagnosed with COVID?

COVID guidelines vary based on destination and are regulated by the local government of the host country.

Yes

If so, what are your isolation arrangements and additional costs associated with housing and meals?

Do you have adequate funding to cover costs associated with a COVID quarantine or isolation period?

Yes

Please describe the planned funding source(s).

Are you prepared to pay for any required COVID testing as needed? Note: AIG insurance does not cover the cost of asymptomatic testing. Contact your domestic insurance provider to see if reimbursement for asymptomatic testing is permitted.

Pre-flight testing guidance: https://www.cdc.gov/coronavirus/2019-ncov/travelers/testing-international-air-travelers.html

Yes

Will you be able to complete your research/study/work remotely, if conditions warrant?

Yes

Are you prepared to financially manage any last-minute change of plans involving transportation and accommodations?

Yes

COVID Prevention

Are you willing to commit to routine COVID-19 mitigation practices, such as wearing a face covering, practicing social distancing, engaging in frequent hand washing/sanitizing, limiting gatherings as directed by a host institution, organization, or government, participating in symptoms reporting or surveillance testing (if required), staying at home if ill, and following guidelines from designated local health authorities?

Yes

Are you able to obtain personal protective equipment (PPE) such as a mask, face shield, hand sanitizer, etc., for your trip?

Yes

Should you need to replace or replenish your PPE during the trip, is it available in your destination?

Yes

Are you, or will you be prior to travel, fully vaccinated against COVID-19?

Please visit the CDC guidance for international travel. Travelers are expected to follow all CDC guidance. https://www.cdc.gov/coronavirus/2019-ncov/travelers/international-travel-during-covid19.html

Yes

If needed, how will you obtain COVID testing in your destination country? Is there an out-of-pocket cost?

Signature Confirmation*

I certify that the information in this application is complete and correct to the best of my knowledge. I understand that travel undertaken is of my own accord. I further understand that I am responsible for maintaining my health and safety during travel, remaining up to date and will follow guidelines and/or requirements from my host country and the US, and notifying UNO of any changes therein. UNO is not responsible for any requirements or restrictions placed on travelers by foreign entities, travel authorities, or the US. I acknowledge that given rapidly changing situations, travel approval may be revoked at any time.

Yes

Print Name of Traveler*

Date Submitted*

Send me a copy of my responses

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