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UMass Chan Medical School
International Pre-Travel Export Control and Risk Form
Once completed,
this form will be emailed to you
and must be attached to the related Pre-Travel Authorization Request in Concur.
Travel Request Name:
(30 characters or less)
(required)
(Use same name and spelling as the “Request Name” field in your Concur Travel Request)
Traveler
Name (First Last)
(required)
(Please use same name and spelling as that in your Concur Travel Request)
Email
(required)
(UMass Chan Medical School email address only)
CC Email
(optional)
Enter an email address here if you would like to CC this form to someone else when it's completed
(UMass Chan Medical School email address only)
Citizenship:
(required)
Please select...
U.S. Citizen
Non-U.S. Citizen
Immigration status (required)
Traveler Type. Select all that apply
(required)
Faculty
Employee
Graduate Student
(If you are both an employee and a student, please check both applicable boxes)
Insurance and Emergency Services
Have you reviewed UMass Travel Accident and Sickness Insurance information?
(required)
Please select...
Yes
No
(
Review UMass International Travel Insurance Brochure
)
Have you downloaded the UMass Travel Accident and Sickness Insurance Travel Card?
(required)
Please select...
Yes
No
(
Download UMass travel accident and sickness insurance Travel Card
)
Traveler Contact Information While Traveling
Mobile Phone: (required)
Email:
In-Country Phone:
(Include country code + city code)
In-Country Address:
Have you traveled to this destination previously?
(required)
Please select...
Yes
No
Describe previous travel experience to this destination, including estimated dates (required)
Please list additional ways in which you can be reached, such as social media.
(e.g. email, WhatsApp, We Chat, Instagram, Facebook name, Twitter name, etc.)
If you anticipate being away from regular email or phone contact, please describe how you will overcome such challenges. (required)
Emergency Contact Information
In-Country/On-site Emergency Contact:
(This can be a member of a partner organization/s, a personal contact, or anyone who will be on-site with you and who can be contacted in the event of an on-site emergency)
(Provide contact information for your in-country partner, collaborator, host organization and/or placement agency. Please list additional partners below if there are more than one contact.)
Name: (required)
Phone: (required)
(Include country code + city code)
Email:
(required)
Personal Emergency Contact:
Name:
(required)
Phone: (required)
Email:
(required)
Primary Campus Contact:
(Campus Contact should be someone who will be in the United States during your Travel)
Name:
(required)
Phone: (required)
Email:
(required)
Describe your plan for communicating with Campus Contact:
(required)
(Please note: communication should include a minimum of a check-in when you arrive on-site, at least one check-in communication during the program, and preferably weekly check-ins.)
Export Control/IT Review (required)
Are you traveling with any of the following? Select all that apply
(required)
Pharmaceuticals for distribution
Research materials, specimens or samples
Items for donation
University Research Equipment
University research materials, specimens or samples
Software not commercially available i.e., proprietary, under an NDA or research agreement
I am not traveling with any of these items
Will you be travelling with a
UMass Chan-owned
computer, tablet or mobile device?
(required)
Yes
No
Please select all
UMass Chan-owned
technology you will be traveling with
(required)
Computer
Tablet
Mobile device
Other (including external drive, flash drive, etc.)
Computer - please enter the computer name or computer serial number: (required)
(
How to lookup your computer name
)
Tablet – please enter the asset tag or tablet serial number: (required)
Will you be travelling with, or will you be accessing
UMass Chan data
from a personal computer, tablet or mobile device?
(required)
Yes
No
I be travelling with, or will be accessing
UMass Chan data
via the following methods. Select all that apply
(required)
Computer
Tablet
Mobile device
Other (including external drive, flash drive, etc.)
Will you be traveling with or accessing sensitive data (related to military contract, PII, proprietary, etc.)? (required)
Yes
No
Select the methods through which you plan to access such data. Select all that apply
(required)
VPN Network
Office 365 (Email, SharePoint, OneDrive, Teams)
Dropbox
SSH (Secure Shell Protocol)
University Travel Policy acknowledgement
(required)
I have read, understand, acknowledge receipt of and agree to abide by the University Travel Policy
(
Review University Travel Policy
)
Program/Host Information
Program Title, Program Purpose/Mission, Host or Collaborating Institution: (required)
Host contact information: (required)
Identify individuals with whom you will be visiting/meeting: (required)
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