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UMass Lowell
International Pre-Travel Export Control and Risk Form
Once completed, this form 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)
(University of Massachusetts 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
(University of Massachusetts email address only)
Traveler Type. List all that apply
(required)
Faculty
Employee
Undergraduate Student
Graduate Student
(If you are both an employee and a student, please check both applicable boxes)
Are you requesting a leave of absence?
(required)
Please select...
Yes
No
Describe leave of absence and list dates (required)
Is there a business purpose to your trip?
(required)
Please select...
Yes
No
Describe business purpose (required)
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)
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? List all that apply
(required)
I am not traveling with any University technology, data or access to University data
University Laptop
University Smartphone
Personal Laptop
iPad
University Research Equipment
University research materials, specimens or samples
University Data (either on or accessed by a personal or University device)
Other technology
Please describe "other technology": (required)
Is the data sensitive (related to military contract, PII, proprietary, etc.)? (required)
Please select...
Yes
No
Select the methods through which you plan to access such data. List all that apply
(required)
VPN Network
Email
One Drive
Other cloud media
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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