Drake University Risk Assessment Committee

DRAKE UNIVERSITY RISK ASSESSMENT COMMITTEE

RISK REVIEW WORKSHEET:

Program Name:

Faculty Leaders:

Country/City/Specific locations(s):

Type of Activity:

Using Provider? If yes, include name:

Program Dates:

Reason for referral to Risk Assessment Committee (to be completed by Drake International staff):

Example: “Medex Threat Rating is 3 or above”

Please provide the following for each program (and attach supporting documentation if available):

General:

ü  Course syllabus (if the trip is attached to a course)

ü  Detailed itinerary for the program, with daily activities

ü  Number of program participants (broken down by students, faculty, staff, etc.)

Transportation and Accommodation:

ü  Accommodation information (contact information and dates at each location)

ü  Flight arrangements (name of carrier, airports they will be flying in and out of, who will provide airport transfer, etc.)

ü  On-site transportation arrangements

Health and Safety:

ü  Any required immunizations for the country or area to which the program will be traveling (www.cdc.gov)

ü  Medex “Medical Risk” rating (to be provided by Drake International staff)

ü  Medex “Threat Rating” (to be provided by Drake International staff)

ü  U.S. Department of State “Country Specific” information (to be provided by Drake International staff)

ü  Information on the third-party provider and/or tour operator being used (contact information, web address, emergency response plan, etc.)

ü  Insurance exclusion activities (to be provided by Drake International staff)

ü  Certificate of liability for the third-party provider or tour operator

ü  Communication modes (ensure that faculty/staff leaders have cell phones that work internationally)

Additional Information:

ü  Information on any visitors that will be accompanying a participant of the Seminar/course (these individuals must sign the “Seminar Visitor Release” form, and may be eligible to purchase FrontierMedex travel insurance).

NOTE: Changes in the security situation or significant changes in the program itinerary will require that the program be re-reviewed by the Drake University Risk Assessment Committee.