Individual International Travelers – Travel Restriction Exception

Request Form (for One-Time Individual Travel)

To be Completed by Requestor

Individual UTSA faculty, staff, and/or students requesting to participate in any UTSA-related activity (including but not limited to programs, exchanges, research, conferences, service learning projects, meetings, teaching endeavors, etc.) in a location listed on the UTSA Restricted Regions List must complete this form.

This request for travel to a restricted region will be closely reviewed by the UTSA International Oversight Committee (IOC). All requests MUST be submitted to the Executive Vice Provost at least 10 working days in advance of proposed travel. No incomplete requests will be accepted. If approved, each traveler must also complete the UTSA High Risk Trip and Project Waiver/Release Form and submit it to the Office of the Provost, prior to departure.

Please note the following exceptions: Individual travelers participating in University-sponsored International Group Travel or Faculty-led Study Abroad programs do not need to complete this form. Instead:

  • UTSA faculty and/or staff organizing and leading international travel events involving the travel of a group of people to a country, region, or area on the UTSA Restricted Regions List should complete the International Group Travel – Travel Restriction Exception Request Form.
  • UTSA departments, faculty, and/or staff proposing to sponsor course-based faculty led international study abroad related travel and programs to a country, region, or area listed on the UTSA Restricted Regions List should complete the International Faculty-Led Programs – Travel Restriction Exception Request Form.

IMPORTANT: Please check this box if you are a UTSA student requesting to travel as an individual (not as a part of a group or faculty-led study abroad international travel activity) to a UTSA restricted region. All students must process through the Office of International Programs in advance of their individual travel. Once approved, the Office of the Provost will forward a copy of this Request Form to the Office of International Programs for the purpose of mandatory student international travel processing.

SAFETY & SECURITY (Please use these resources to gather safety and security information about the restricted location to which you are proposing to travel):

International SOS is the UT System contracted international emergency assistance provider. The website is and our UTSA membership ID is 11BSGC000037. Enter the membership number ID to enroll yourself and access the up-to-date country-specific medical and safety information that International SOS provides.

You are required to register with International SOS. Travelers who use one of UTSA’s travel agencies to schedule transportation are automatically registered with International SOS. Because of this, individual travelers are strongly encourage to us a UTSA contracted agency to schedule your travel.

If a University-contracted agency is not used, then the traveler must manually register his/her travel itinerary in the International SOS database, attach written proof of this SOS registration to the completed UTSA High Risk Trip and Project Waiver/Release Form, and then submit both forms to the Executive Vice Provost, prior to departure.

The U.S. Department of State website is lists country-specific warnings and alerts, while advising U.S. citizens on risks related to travel in specific countries.

Name of Requestor:

Last First Middle

Title Department College
Country(s) of Destination (Cities and States –be specific) and Risk Category (1,2, or 3):
Exact Travel Dates (In-Country Dates):
Your Detailed Travel Itinerary (all travel taking place between the above Travel Dates):
Mode of Travel (Include all modes of transportation: plane, train, auto, public transportation, etc.):
Lodging/Accommodations (include address, telephone/fax numbers, e-mail):
Traveler’s level of familiarity with region/area of proposed travel, including the Language Proficiency of Traveler(s):
Purpose of Proposed Travel (Include necessity/justification of travel to restricted country and implications of not traveling to the requested destination):
Planned Safety Precautions for Travel and Stay:
List any other considerations you believe to be relevant to the IOC review:

Traveler’s Emergency Contact Information While Abroad

It is important that UTSA has the necessary information immediately available to us, in the event that an emergency or unexpected event makes it necessary for the University to locate you during your proposed UTSA related travel in a restricted travel region. Please provide the following information so that UTSA and/or outside sources may know how to contact or communicate with you in the event of an emergency:

Traveler Name as it appears on Passport:
International Cell Phone:
Additional phone numbers (cell/work/home):
E-mail:
Physical Address of all locations where you will be staying:

Alternate Emergency Contact Information While Abroad

Please provide an alternate person that UTSA and/or outside sources may use to communicate with you in the event of an emergency:

Name: / Relation to Traveler:
Physical Address:
Phone numbers (cell/work/home):
E-mail:

Signature of Requestor

Signature Date

Department/College/Provost/VICE PrESIDENT Review

Note: Administrative officers and staff in administrative portfolios, including those of the President, Provost, and other Vice Presidents proposing to travel in a restricted region should submit a completed Individual Travelers – Travel Restriction Exception Request Form to his/her immediate supervisor for approval.
Approval of Department Chair:
Name: Signature:
Department: Date:
Approval of College/School Dean (or Vice President, President, or Executive Vice Chancellor, as appropriate):
Name: Signature:
Department: Date:

Submitting your request:

After the Department Chair and Dean have signed above, please forward this request to:

Julius M. Gribou, AIA, IIDA

Executive Vice Provost

Senior International Officer

Main Building 4.120

University of Texas at San Antonio

Fax: (210) 458-4115

REMINDER: All requests MUST be submitted to the Executive Vice Provost at least 10 working days in advance of proposed travel. No incomplete requests will be accepted.

IOC Review and Approval:
Date of Review by the IOC
Approval or disapproval by the UTSA Executive Vice Provost, based on the review and recommendation of the IOC:
Approved Disapproved
Name: Signature: Date:

Was your request for a travel exception approved?

If so, please remember that in addition to submitting the UTSA High Risk Trip and Project Waiver/Release Form to the Office of the Provost,all travelers are also required to register withInternational SOS, UTSA’s emergency assistance provider prior to departure. Travelers who use one of UTSA’s travel agencies to schedule transportation are automatically registered with International SOS. Because of this, individual travelers are strongly encouraged to use a UTSA-contracted agency to schedule transportation.

If a University-contracted travel agency is not used, then the traveler must manually register his/her travel itinerary into the International SOS database, attach written proof of his/her SOS registration to the completed UTSA High Risk Trip and Project Waiver/Release Form, and then submit both forms to the Executive Vice Provost prior to departure.

Was your request for a restricted travel exception disapproved?

If a travel exception is not granted (for an individual or program), the proposed traveler(s) are not allowed to travel to the restricted region. Travelers who engage in unauthorized travel may be subject to disciplinary action, and any expenses associated with such travel will not be reimbursed.

NOTE: Due to the dynamic nature of risk management concerns for any given country, any IOC recommended and Executive Vice Provost approved exception applies only to one trip and only for the stated duration of “in-country dates” as provided above. Future travel to a restricted country will require a new request to the IOC for exemption. UTSA reserves the right to recall exempted travelers on short-notice if risk management circumstances warrant such action.

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