Risk Management
P.O. Box 6000, Binghamton, NY 13902-6000
(607) 777-7475
FAX (607) 777-6453
4000 Vestal Parkway East, Vestal NY 13850
Risk Management Use ONLY
Date Rec’d: _______________
Authorization Recommended: Yes / No
RM: __________________
Auth: __________________
Faculty / Staff/ Student Request to Travel to Countries with Travel Warnings (CTW)*
Binghamton University is committed to helping its faculty, staff and students to be as safe as possible while travelling abroad.
Although no single plan will address all health, safety and security contingencies, the University recognizes the importance of
establishing travel guidelines and promoting practices that consider: 1.) principles of prudence and essentiality and 2.) areas
where there is a strong probability that travelers could face health, safety and security problems. It is the intent of
Binghamton University to require faculty, staff and students to receive authorization before traveling to a Country with Travel
Warnings (CTW).* Binghamton University travelers should understand and be adequately prepared to mitigate the health,
safety, and security risks associated with their travel to a CTW. The information collected through this process benefits the
traveler and the University in its capacity to provide assistance in the event of an emergency or crisis. In the case where Risk
Management deems the risk to be too high, travel will not be authorized.
*Countries with Travel Warnings (CTW)
Risk Management, using current resources which indicate a significant level or an extreme level of risk, is responsible for
determining CTW. These are countries where threat levels may compromise the personal health, safety and security of
Binghamton University travelers and potentially threaten future opportunities for the University. The primary CTW resource
is the U.S. Department of State Alerts and Warnings (http://travel.state.gov/content/passports/english/alertswarnings.html)
and is supplemented by the Center for Disease Control Travel Health Notice (“Warning Level 3” and “Alert Level 2” listed
countries: http://wwwnc.cdc.gov/travel/notices) and the Overseas Security Advisory Council (http://www.osac.gov). Absence
of a country from any of these resources does not indicate that a location is safe or without travel risk. Lists change and links
should be checked to see if warnings have changed.
Instructions
Provide this original signed request form with the original signed “Request and Authorization to Travel” to Risk Management.
If travel is SUNY Research Foundation-related this form must be sent to Sponsored Funds prior to Risk Management. Prior
external sponsor approval to conduct research in a CTW does not mean the travel has been authorized by the University.
ALL requests must be received by Risk Management prior to departure date.
Traveler Details
Name as it appears
on Passport:
B-Number
Title/ Position
Email:
Office Phone
Mobile Phone
Department/Unit:
Description of Travel
Purpose of Travel (brief - additional
explanation space provided on p 3):
Location - Country(ies) & City(ies):
Beginning and End Dates of Travel:
Funding Source(s):
Date
Leave US
State
Date Return to US
IFR
BU Foundation
RF
Self
Other -
Required Signatures
Traveler:
Today’s Date:
Signature of Traveler
Approver:
Today’s Date:
Dean, Vice President or Delegate
Signature of Approver
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Printed Approver Name
rev: 25 March 2016
Emergency Contact Info
ALL MUST COMPLETE. Students hereby recognize in the case of disaster or emergency that their information
may be disclosed as determined by exception to the Family Educational Rights and Privacy Act - see
http://www2.ed.gov/policy/gen/guid/fpco/pdf/ferpa-disaster-guidance.pdf
U.S. Emergency Contact Person
Provide information for your chosen US emergency contact for use in the event of an emergency or crisis.
E-mail:
Contact Name:
Mobile
Relation to Traveler:
Phone:
U.S. Emergency
Home
Contact Physical Home
Phone:
Address:
U.S. Emergency
Work
Contact Physical Work
Phone:
Address:
Binghamton University Emergency Contact / Travel Manager
Provide a departmental contact for response personnel to work with in the event an emergency or crisis.
Binghamton University
E-mail:
Contact Name & Title:
Binghamton University
Mobile
Contact Department:
Phone:
Office
Phone:
Home Address of
Home
Binghamton University
Phone:
Contact:
In-Country Emergency Contact
Provide a contact for for response personnel to work with in the event an emergency or crisis.
In-Country
E-mail:
Contact Name & Title:
Affiliation to Traveler:
Mobile
Phone:
Office
Phone:
Home Address of
Home
Contact:
Phone:
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rev: 25 March 2016
Attach additional sheets if necessary.
EXPLANATION OF TRAVEL Provide a statement detailing the compelling reason why travel must take place in the
proposed location and why you cannot engage in either a similar or alternate program in a different location. The fact that
an external sponsor may have approved the research appropriateness does not eliminate the need to respond.
ITINERARY, DESTINATIONS and TRANSPORTATION Provide a complete itinerary of your travel (as complete as
possible), including all departure/arrival dates and locations, airline flight #’s, accommodation and locations, and intended
modes of transportation between all points, if known, as destinations can be credit and/or cash economies. Include reference
to getting from the airport to your place of work or lodging, daily transportation, etc. To the extent that your transportation
will involve either taxis, bus or public transit systems, how well do you know the risks associated with each in your destination
country/city, or what steps will you take to mitigate those risks? Any changes to the itinerary subsequent to submission of this
document are to be forwarded to the traveler’s Department Director or Dean, Vice President, and Risk Management.
RISKS What are the particular risks associated with travel in this location (in terms of geographic locations and/or activities)?
How have you planned to minimize those risks to the extent possible?
How will you ensure that you have sufficient resources in the right currencies to be able to do what you need/want to do while
in country? To what extent will you rely on cash or credit? Are ATMs or exchange houses readily accessible and safe? Do
mobile phones work everywhere on your route(s)?
LANGUAGE What is your level of language proficiency in the native language of the country to which you are traveling? To
what extent and in what contexts are transactions conducted in the native language, English or other languages? If you do not
have the language skills yourself, how have you arranged to be able to effectively communicate (regarding transportation,
lodging, research, emergency situations, health needs)?
COMMUNICATIONS What plans do you have in place to maintain regular contact with someone in the United States and
under what circumstances would they notify the University if they did not hear from you as expected?
What will be your means of communication domestically and internationally while you are in country? Will you have cell phone
service, Wi-Fi, satellite phone, or other form of communication?
CANCELLATION Under what circumstances would you cancel your plans to go on this trip? What steps have you taken to
have the information necessary and to facilitate that change should it be necessary?
PACE This is where you describe your overall approach to planning using the PACE model: Primary, Alternate, Contingency
and Emergency preparations and action plans.
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rev: 25 March 2016
TRAVELER MITIGATION OF RISK
1. The U.S. State Department maintains lists of country-specific Travel Warnings and Alerts for U.S. citizens.
The website is www.travel.state.gov. By initialing the box below, you are confirming that you have read
and understood the current U. S. State Department Travel Warnings and Alerts for this destination or
destinations (if applicable). The traveler hereby agrees to continue to refer to the U.S. State Department
Travel Warning and Alerts throughout the duration of this travel.
Traveler Acknowledgment of U.S. State Department Travel Warning/Alert
2. The Centers for Disease Control maintains a list of country-specific Travel Health Notices. The website is
http://wwwnc.cdc.gov/travel/notices. By initialing the box below, you are confirming that you have read
and understood the current CDC Travel Health Notices for this destination or destinations (if applicable).
The traveler hereby agrees to continue to refer to CDC Travel Health Notices throughout the duration of
this travel.
Traveler Acknowledgment of CDC Travel Health Notices
3. Travel to any CTW involves degrees of risk. The Risk Notification Statement (last page of this document)
provides information on many of those risks and resources for mitigating them. By initialing the box
below, you are confirming that you have read and understood the Risk Notification Statement and will
continue to refer to the U.S. State Department Travel Warning and Alerts throughout the duration of this
travel.
Traveler Acknowledgment of Risk Notification Statement
4. No Binghamton University student, faculty, or staff can be required to travel to a Restricted Region. By
initialing the box below you are confirming that any participation in travel to a Restricted Region is truly
voluntary, and you assume full responsibility for all risks associated with this travel.
Traveler Voluntarily Traveling to a Restricted Region
5. Insurance is required. If funding for travel is from the Research Foundation, I have secured the free of
charge Foreign/International Travel Benefits Programs such as FrontierMedex and Geo Blue Traveler.
Contact the travel unit in Sponsored Funds Administration at 607-777-6752 or visit
http://research.binghamton.edu/SponsoredFunds/Travel.php#Foreign for additional information.
Travelers not using RF funds must obtain coverage through OIP/ISSS
Traveler has obtained or will obtain Foreign/International Travel Benefits Programs
such as FrontierMedex and Geo Blue Traveler (RF) or SUNY Overseas Insurance (State,
IFR, Self, Other Funding)
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rev: 25 March 2016
RISK NOTIFICATION STATEMENT
It is the intent of Binghamton University to review requests for international travel to any CTW. Travel to any CTW involves
certain degrees of risk. It is important to ensure that contingency plans are in place to deal with emergencies. When risks are
realized and emergencies strike, response can be complex. Travelers are encouraged to consider risks and develop
contingency plans in advance of a problem. Contingency plans may include alternate transportation means or procurement
of a satellite communications device with US State Department, US Consulate/Embassy numbers pre-programmed for fast
deployment should conditions warrant.
It is important that you UNDERSTAND & CAREFULLY CONSIDER THE FOLLOWING RISKS:
 The US Embassy nearest your destination may temporarily close or suspend public services for security reasons.
 The US Embassy nearest your destination may not be able to provide emergency assistance should you require it.
 If there is a need to evacuate in an emergency flights may be suspended, and other departure or shelter options may be
limited or non-existent.
 Access to hospitals, emergency medical care and medications may be limited or non-existent.
 Should you experience difficulties, Binghamton University may not be in a position to provide emergency assistance to
you.
 Participation in travel to a CTW has inherent risks, which may include kidnapping or death. These risks can never be
completely eliminated.
 Risks of travel to your destination, may include (but are not limited to) dangers to health and personal safety, including
possible death posed by natural disaster, disease, terrorism, crime, civil unrest, and/or violence.
 Additional risks include (but are not limited to) minor and major physical injuries, emotional and psychological injuries
inflicted accidentally or intentionally by others, and/or catastrophic injuries, including paralysis and death.
 There may be additional health, safety, and security factors that have not been brought to your attention by
Binghamton University.
IT IS HIGHLY RECOMMENDED THAT YOU VISIT & CAREFULLY REVIEW THE FOLLOWING WEBSITES:

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http://www.binghamton.edu/travel/travel.html Binghamton University Travel Information
http://www.binghamton.edu/travel/overseas.html Binghamton University Overseas Insurance Program
http://travel.state.gov/content/passports/english/alertswarnings/worldwide-caution.html US Department of State
Worldwide Caution
http://www.travel.state.gov US Department of State website for Travel Warnings, advisories, and consular
information sheets for the intended destination
http://www.cdc.gov US Center for Disease Control and Prevention website for information on health issues and
recommended vaccinations for travel to intended destination – see also http://wwwnc.cdc.gov/travel/
http://www.who.int World Health Organization website for information on disease outbreaks and emergencies
https://portal.rfsuny.org/portal/page/portal/policies/travel_handbook.pdf Research Foundation for SUNY Travel
Handbook, please see page 31 regarding International Travel
http://www.osac.gov Overseas Security Advisory Council
ACKNOWLEDGMENT STATEMENT
No Binghamton University student, faculty, or staff can be required to travel to a CTW.
By submitting this signed request, the traveler confirms that any participation in travel to a CTW is truly voluntary and
assumes full responsibility for all risks associated with this travel.
__________________________________________ _______________
Traveler signature
Date
______________________________________ _______________ ____________________________________
Witness signature
Page 5 of 5
Date
Witness Name Printed
rev: 25 March 2016