International Travel Form GROUP For Credit

HAVE ALL YOUR INFORMATION TOGETHER BEFORE BEGINNING THIS FORM.
Review the International Travel Policy.
All fields on this form are MANDATORY for the purposes of registering your travel with the WFU/Crisis24 Horizon system.
This form should be completed as soon as possible prior to traveling so that we have sufficient time to register your travel and purchase international health insurance.
IF THERE IS MORE THAN ONE GROUP LEADER, EACH LEADER SHOULD COMPLETE THIS FORM.

Electronic Signature of Group Leader*

By signing below, I confirm that I have read the International Travel Policy. I understand that for reasons of security/safety, WFU may deny funds for travel outside the United States at any point prior to departure. However, I understand and acknowledge that the provision of funds for international travel does not imply that Wake Forest University accepts responsibility for any risks associated with the travel. In addition, I understand that I may be required to attend a security briefing prior to departure. I understand that I must submit all required forms to GPS and perform all required tasks before departure.

Name of Department*

Please provide the name of your department and the email address of your Department Chair, Unit Head or Dean. This form will be routed for the appropriate signature.

Name of Supervisor, Department Chair or Dean*

Email of Supervisor, Department Chair or Dean*

Group leader(s) must turn into GPS*

(Check your acknowledgement of each item)

International health insurance (GeoBlue) enrollment form. NOTE: The cost of this insurance will be billed to the program.

Faculty/Staff Assumption of Risk & Release form and Assumption of Risk & Release – OTHER, if traveling with another person (e.g. spouse or child)

Faculty/Staff Director Guidelines form (completed and signed by Faculty/Staff Director)

These forms are located at International Travel Forms GROUP For Credit

Name of Traveler*

First Middle Last

WFU ID (8 numbers, include leading 0 if applicable)*

Email*

Cell or Home phone*

Unit (select one)*

College

Business School

Graduate School

Law School

Divinity

Other

Affiliation*

Faculty

Staff

Other

Begin date of actual travel*

End date of actual travel*

Purpose of travel*

(Ex. independent research, conference, scholarship recipient, professional development)

Questions for Travel Authorization

Will you be traveling with university owned computer(s) or external device(s), remotely accessing WFU information systems and servers, or traveling with tangible materials or other university owned equipment?*

Yes

If yes, please describe these in detail, including value, property tag numbers, and/or serial numbers, if available:

Will you be traveling with or accessing any WFU proprietary information or materials not intended for public access?*

Yes

If yes, please describe in detail the information or materials:

With whom will the information or materials be shared?

Will you be traveling with or accessing any sensitive, regulated, export-controlled, controlled unclassified, or intellectual property information, data, equipment, or technology during the course of your travel?*

Yes

Note: This question includes information, data, equipment, and technology that is controlled by any federal, state, university, or contractual law, regulation, or obligation. Examples Include: Export Administration Regulations (EAR), International Traffic in Arms Regulation (ITAR), Controlled Unclassified Information (CUI), Health Insurance Portability and Accountability Act (HIPAA), Family Educational Rights and Privacy Act (FERPA)

If yes, please describe in detail the information, data, equipment, or technology:

With whom will the information, data, equipment, or technology be shared?

Is this information, data, equipment, or technology associated with any sponsored research? If so identify the sponsor and award ID:

Is this travel part of your contractual obligations for sponsored research where the sponsor or prime contractor is a U.S. Government agency, corporation or private foundation?*

Yes

If yes, please include the name of the agency/corporation/foundation and award ID:

Itinerary

FIRST international destination (City & Country)*

Begin date in FIRST destination*

End date in FIRST destination*

FIRST destination hotel/accommodation (name, address, phone number)*

If you do not have your accommodation information at this time, “TBD” is acceptable here. Once your plans are finalized, submit AS SOON AS POSSIBLE to GPS.

SECOND international destination (City & Country)

Begin date in SECOND destination

End date in SECOND destination

SECOND destination hotel/accommodation (name, address, phone number)

THIRD international destination (City & Country)

Begin date in THIRD destination

End date in THIRD destination

THIRD destination hotel/accommodation (name, address, phone number)

If traveling to MORE than THREE destinations, upload a file with your complete itinerary

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 32 MB.

Domestic Emergency Contact Information

Name*

First Last

Relationship to you*

Cell or Home phone*

Address*

Street Address Address Line 2 City State ZIP Code

Email of emergency contact

Additional overseas contact if available (name, address, phone)

Phone

This field is for validation purposes and should be left unchanged.

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International Travel Form GROUP For Credit

GROUP International Travel Form FOR CREDIT

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