Special International Travel Registration and Waiver Form

In compliance with UMMS travel policy, anyone traveling under the University of Massachusetts Medical School auspices must complete this travel registration form. The information provided is needed for UMass-sponsored AIG international travel insurance, which covers everyone traveling in connection to their work or study at UMMS, and to help us provide assistance should emergencies arise during travel.

The UMMS travel policy prohibits Students (Medical School, Graduate Nursing School and Graduate School of Biomedical Sciences) from traveling to countries on the US State Department Warning or Alert list.

* Indicates a required field

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TRAVELER INFORMATION

Full Name*  
Department/Program* 
Name of dept. head approving travel*
 
Other department     
 
Email* (enter only 1 email)
  You may enter Administrator email
Phone Number* 
Status* 
Citizenship* 
Who is your employer* 

LOGISTICAL INFORMATION

Destination(s)* 
Accommodations* 
Departure Date* 
Return Date* 
Global Phone Number* 
Travel Companion(s)* 

PROGRAM INFORMATION

Program/Organization Name* 
Program Contact (Name, Title, Email, Phone, Website)* 
Purpose and Goals of Travel (select only one)* 
  
Will you be doing any clinical work?


UMass Memorial/UMMS employees/students are covered for professional liability by the UMass Memorial Health Care, Inc, Self Insurance Program for clinical activities when they travel worldwide provided they have approval to do so. However, this professional liability coverage is limited as follows:

  • Employees and Students are only covered for approved University business or activities during the dates of travel stated in the travel registration form.
  • Medical staff will only be covered for activities approved within their license.
  • Students and trainees will only be covered for activities approved within their level of education and training according to the UMMS curriculum. As of December 12, 2013, medical students are only approved for clinical work appropriate to their education level and under the following conditions:
    • Provision of liability coverage by the host institution, documentation required;
    • Provision of adequate clinical liability coverage by a third party, documentation required.
    • Unless one of these circumstances is met, medical students are not permitted to complete clinical international electives. Students must meet with Dr. Melissa Fischer prior to travel approval to discuss their insurance coverage

  • Any resulting suit/legal litigation must be filed in the United States, its territories and/or Canada.

It is the strong recommendation of UMMS that you purchase additional professional liability insurance coverage from the country of destination when you travel out of the United States to ensure proper insurance coverage for any suits/legal litigation brought against you in your country of destination.

  
If presenting or lecturing, indicate talk title(s) and/or topic(s) 
Are you shipping or bringing with you physical goods or materials that may be subject to Export Control and Sanction laws? (See the EAR Commerce Control List.)* 
Rationale for continued plans to travel to said destination(s) despite existing US State Department Travel Warning and/or Travel Alert* 

EMERGENCY CONTACT INFORMATION

In-country emergency contact:All International travelers should have an in-country emergency contact. This could be a conference or program organizer, collaborator contact, or family member who will be in the country at the same time as your travel dates.
Name* 
Relation* 
Email* (enter only 1 email)
 
Phone* 
In-country emergency contact:This in-country emergency contact should be different than the one previously listed.
Name* 
Relation* 
Email* (enter only 1 email)
 
Phone* 
US emergency contact:Your US emergency contact should not be the same as your in-country emergency contact.
Name* 
Relation* 
Email* (enter only 1 email)
 
Phone* 
Please indicate your plans for accessing emergency medical care:*Example: Contacting the in-country emergency contact, proceeding to the nearest hospital (hospital name/address), etc.
Please indicate your crisis communication plans*Example: Contacting the in-country emergency contact, contacting the nearest US Embassy or Consulate, calling the number on the AIG travel insurance card, etc.
I acknowledge that it is my responsibility to consult US State Department Travel Warnings/Alerts and CDC Travel Health Notices for travel advice and entry/exit requirements. I will obtain travel approval from your program director and OGH if traveling to a country or region with a Warning or Alert.
I acknowledge that I will obtain current travel health information and necessary vaccines & medications for my travel (See  or the UMass Memorial Travel Clinic).
I acknowledge that I will register my travel with the US State Department through the Smarter Traveler Enrollment Program. This will allow the Department of State and the local Embassy or Consulate to better assist me in the event of an emergency.