TRAVEL RISK ASSESSMENT FORM

PERSON OR GROUP NAME	DATE OF DEPARTURE	DATE OF RETURN
DESTINATION

PERSON(S) TRAVELING

NAME (LAST, FIRST)	ROLE	CONTACT INFORMATION

ALL COUNTRIES / AREAS TO BE VISITED

AREA	PURPOSE	DATE OF VISIT

LATEST GUIDELINES OR RECOMMENDATIONS REGARDING TRAVEL TO AREAS LISTED

AREA	RISK TYPE (e.g. political, economic, sanitation)	RECOMMENDATION

RISK ASSESSMENT

Yes	No	ASSESSMENT	NOTES
Has each traveler discussed general and specific health risks related to this trip with their doctor?
Are there specific health hazards in the area of travel including, but not limited to, animals, disease, pollution, altitude, allergies, weather, radiation, or sanitation?
Will there be easy access to medical aid?
Are there specific physical safety concerns in the area of travel including, but not limited to, civil unrest, religion, legalities, customs, or clothing?
Are there concerns with transportation within the area of travel? (e.g. suitable vehicles available, competent drivers for terrain type, necessary permits)
Will travelers be carrying cell phones with them during the trip? Will the cell phones have international roaming activated?
Has each traveler provided emergency contact information?
Do travelers have local phone numbers to call in the case of an emergency?
Have emergency first aid arrangements been made?
Are contingency plans in place in the case of travel or plan interruption?

RISK MANAGEMENT PLAN

RISK	ACTION PLAN	RESPONSIBLE PARTY

AFFIRMATION OF PERSON COMPLETING TRAVEL RISK ASSESSMENT

I have requested that all persons travelling notify me of any existing medical conditions, and to the best of my knowledge all travelers are physically and mentally fit to travel. All travelers are responsible for any medication they may require. I have also checked federal travel guidelines and local sources at my area of intended travel to ensure that I won’t be placing myself or others in harm’s way during travel.

PRINTED NAME AND TITLE	SIGNATURE	DATE

AFFIRMATION OF APPROVING OFFICIAL

I have reviewed this travel risk assessment and approve of all information provided herein.

PRINTED NAME AND TITLE	SIGNATURE	DATE

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