International Travel Registration

TRAVELER INFORMATION

 

LOGISTICAL INFORMATION

PROGRAM INFORMATION

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.

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.

US emergency contact: Your US emergency contact should not be the same as your in-country emergency contact.

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 ACE travel insurance card, etc.

\n\n

\n", workingFormInfo = event.workingFormInfo, searchPattern = null, $workingForm = workingFormInfo.$workingForm, $currentElement = $("#3bcf263f-acbf-4dc7-8804-6628bfda2d52", $workingForm); // if cannot find the element in form, do nothing if (!$currentElement || $currentElement.length == 0) { return; } var data = epi.EPiServer.Forms.Data.loadCurrentFormDataFromStorage($workingForm); // replace placeholder with real field value for (var fieldName in workingFormInfo.ElementsInfo) { if (workingFormInfo.FieldsExcludedInSubmissionSummary.indexOf(fieldName) != -1) { continue; } var elementInfo = workingFormInfo.ElementsInfo[fieldName], friendlyName = elementInfo.friendlyName; if (!friendlyName) { continue; } var value = elementInfo && elementInfo.customBinding == true ? epi.EPiServer.Forms.CustomBindingElements[elementInfo.type](elementInfo, data[fieldName]) :data[fieldName]; if(value == null || value === undefined) { value = ""; } searchPattern = new RegExp("#" + friendlyName + "#", 'g'); text = text.replace(searchPattern, $('
').text(value).html()); } $currentElement.html(text); })($$epiforms); }); }); }

Verify Information

Please, verify information and submit the form:

Full Name:
Department/Program:
Name of dept. head approving travel:
Other department:
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:
Will you be doing any clinical work? 

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?:

EMERGENCY CONTACT INFORMATION
In-country emergency contact:

Name: 
Relation: 
Email: 
Phone: 

US emergency contact:

Name: 
Relation: 
Email: 
Phone: 

Please indicate your plans for accessing emergency medical care: 

Please indicate your crisis communication plans: 

 

Student and Trainee Travel Liability Waiver for all International Travel
For all SOM Student, GSBS Graduate Student, GSN Graduate Nursing Student, Post-doc Fellows, Residents and Medical Fellows

 

THIS IS A RELEASE and WAIVER OF LEGAL RIGHTS
READ AND UNDERSTAND BEFORE SIGNING

 

ASSUMPTION OF RISK AND GENERAL RELEASE FORM

 

I am a student, graduate student, graduate nursing student, resident or fellow at the University of Massachusetts Medical School (UMMS) and have received funding and/or will receive academic credit for research, study, work or travel in a foreign country or countries (the “Project”). I have chosen to undertake this Project voluntarily. I was not required to undertake this Project as a condition of receiving my degree or completion of my training. In connection with my trip with an official UMMS project to the above-referenced destination(s), this agreement confirms my understanding of the following:

1. Risks of International Travel. I understand that participation in the Project and international travel involves risks not found in study at UMMS. These include, without limitation, risks involved in traveling to and within, and returning from, international locations; foreign political, legal, medical, social and economic conditions; different standards of design, safety and maintenance of buildings, public places and conveyances; and local weather conditions. The country or countries to which I will travel may have health and safety standards substantially below those enjoyed in the United States, and I recognize that I may be subjected to potential risks, illnesses, injuries and even death. I have made my own investigation of these risks, understand these risks and assume them knowingly and willingly. I also acknowledge that in working, living and traveling in cities abroad, I may experience problems associated with urban living, including increased crime, pollution, high population density or standards of living and health standards that are not equivalent to life in the United States. I will take every precaution to safeguard my health and to protect my personal belongings from damage or theft. I acknowledge that UMMS recommends that I never travel alone, particularly at night. Being alone, especially at night, may present additional danger to my safety and well-being.

I acknowledge that students, graduate students and graduate nursing students are not allowed to travel to countries on the U.S. State Department Warning or Alert list and that only post-doc fellows, residents and clinical fellows are allowed to request a waiver to travel to such countries. I also have read and understood the U.S. Department of State Consular Information Sheet about the country or countries to which I am travelling (available on the State Department website at http://travel.state.gov).

2. Health Insurance; Medical Care; Health and Safety Concerns. I understand that I am responsible for obtaining any recommended immunizations before traveling to my destination. I carry valid and current medical insurance and have a valid insurance identity card to bring. I have determined that this insurance is adequate to cover injuries or illnesses that I may sustain while participating in the Project. I will be responsible for payment in full of all costs of medical care I may receive overseas.

I am also aware that, during my participation in the Project, upon registering my travel with the Office of Global Health and receiving an approval for travel, I will be enrolled in the UMMS A&H Ambassador Travel Accident and Emergency Sickness Insurance. I understand and agree that if, during my participation in the Project, UMMS learns that I am experiencing serious health problems, have suffered an injury, or am otherwise in a situation that raises significant health and safety concerns, then UMMS may contact my parents or any other person whose name I have provided as my “emergency contact.” I understand that UMMS ordinarily will not initiate such contact without first having a discussion with me.

Before departure, I will enroll in the U.S. State Department Smart Traveler Enrollment Program (STEP) traveler registration program.https://travelregistration.state.gov/ibrs/ui/

3. Professional Liability Insurance. I understand that UMass Memorial/UMMS employees/trainees 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: 

    1. Employees and trainees are only covered for approved University business or activities during the dates of travel stated in the travel registration form.
    2. Medical staff will only be covered for activities approved within their license.  
    3. Graduate level trainees (residents and fellows) will only be covered for activities approved within their level of education and training according to the UMMS curriculum.
    4. Any resulting suit/legal litigation must be filed in the United States, its territories and/or Canada.
    5. 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.

As of December 12, 2013, medical students are only approved for international clinical rotations 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, OUME, prior to travel approval to discuss their insurance coverage.

 

4. Standards of Conduct. I recognize that I assume an important personal obligation to conduct myself in a manner compatible with local laws and regulations; with UMMS’s policies for student conduct (including without limitation those set forth in the UMMS Student Handbook and in any Project-specific materials); and with the policies of my host institution (if any). I promise to act responsibly and will become informed of, and will abide by, all such laws, regulations, policies and standards. I will comply with UMMS’s policies, standards and instructions for student behavior. I agree that UMMS has the right to enforce all standards of conduct described above.

5. Travel Arrangements. I understand that UMMS does not represent or act as an agent for, and cannot control the acts or omissions of, any host family, employer, transportation carrier, hotel, tour organizer or other provider of food, goods or services involved in the Project. I understand that UMMS is not responsible for matters that are beyond its control, and that it cannot warrant the safety or convenience of the circumstances under which I will be living or working.

6. GENERAL RELEASE. Knowing the risks described above, I voluntarily agree, on behalf of myself, my family, heirs and personal representative(s), to assume all the risks and responsibilities surrounding my participation in the Project. I also agree to release, hold harmless, and indemnify UMMS and the University of Massachusetts, and its officers, trustees, directors, faculty, staff, representatives, employees and agents, from and against any and all present or future claim, loss or liability for injury to person or property which I may suffer, or for which I may be liable to any other person, related to my participation in the Project (including periods in transit to or from my destination), resulting from any cause, including but not limited to ordinary or gross negligence. 

I have carefully read and freely signed this Assumption of Risk and General Release Form. I understand and agree that no oral or written representations can or will alter the contents of this document. I agree that this agreement shall be governed by the laws of the Commonwealth of Massachusetts (excluding its conflict of laws principles), which shall be the forum for any lawsuits filed under or incident to this agreement or the Project.

▴ Back To Top
Section Menu To Top