International Pre-Travel Export Control and Risk Form
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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)
Department (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)
Please indicate the purpose of your travel (check all that apply): (required)
Attending a Conference
Clinical Care
Collaboration
Delivering a talk or presentation
Education Elective
Research/Grant
Training
Other
Delivering a talk or presentation, please describe the content of your presentation. (required)
Please describe "Other" purpose of travel: (required)
Funding Type
(required)
Grant
Host/Sponsor
School/Dept
Self
Other
Please explain "Other" funding type (required)
Is the host/sponsor a domestic or foreign entity? (required)
Please select...
host/sponsor is a domestic entity
host/sponsor is a foreign entity
Please provide the name of the host for "Host/Sponsor" funding type (required)
Will you be traveling to or through high-risk locations as determined by the Systemwide Travel Risk Management Advisory Committee (TARMAC): Please use the Risk Lookup to check. (required
)
Please select...
Yes
No
(
Risk Lookup
)
Most high-risk destinations also meet the TARMAC criteria for
elevated cybersecurity risk
. If that is true of your destination, Research Compliance and/or IT will contact you about cybersecurity risk mitigation measures, including utilizing a loaner laptop for your travel.
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:
(Provide contact information for your non-U.S. in-country partner, collaborator, host organization and/or placement agency. Please list additional partners below if there is 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)
Please provide details about your travel such as conference name and website link, research description, institutions you plan to visit, or other travel purpose details. (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, FERPA, Protected Health information (PHI), Personally Identifiable Information (PII), proprietary, etc.)?
(required)
Yes
No
Reference Links:
FERPA
|
Protected Health Information
|
Personally-Identifiable Information
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)
*RDP (Remote Desktop Protocol)
*Please be aware that remote access to data center resources via VPN, SSH or RDP is prohibited from high-risk locations. Please see
International Travel (sharepoint.com)
for additional information.
Will you access, discuss or present data governed by an agreement with publication restrictions or access restrictions?
(required)
Please select...
Yes
No
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
)
Travel Date Change Acknowledgement
(required)
I understand that I must immediately inform International Support Services if my travel dates change and/or exceed three months.
(
International Support Services
)
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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