MISSOURI S&T
PROPOSAL FOR
STUDY ABROAD SHORT-TERM FACULTY-LED PROGRAM
FORM 4SAFETY, RISK MANAGEMENT & INSURANCE FORM
To helpyou are prepare for possible emergency situations while on your Study Abroad Short-Term Faculty-Led Program, a faculty member must submit responses to each of the questions or statements listed below.Keep in mind, Program Directors should be the first contact in dealing with any crisis management.
Once completed please send:
- 1 printed version of each page and any attachments with original signatures to Office of International and Cultural Affairs, 104 Norwood Hall, Attn: Robin Ziegler/Study Abroad
- Electronic version of each completed form and attachments (no signatures required) to Robin Ziegler at .
- Additional pages may be attached as needed to list more locations, lodging, activities, etc
Title of program: Click here to enter text
Program Directors information
Name: Click here to enter text.
Department: Click here to enter text.
Email:Click here to enter text.
Campus phone extension:Click here to enter text.
Cell Phone number to be used during travel abroad: Click here to enter text.
Name: Click here to enter text.
Department: Click here to enter text.
Email: Click here to enter text.
Campus phone extension: Click here to enter text.
Cell Phone number to be used during travel abroad: Click here to enter text.
Student Information
The maximum number of participants is 15 per program director. Please assure you have either co-directors or an official student assistant to accommodate the number of students.
Expected number of students: Click here to enter text.
Pre-departure Orientation
Orientation is mandatory for all individuals participating in the program. During the pre-departure orientation Program Directors should be prepared to cover their Emergency Plan. Please plan to provide students with a 24-hour emergency contact phone number, the contact information for the nearest U.S. Embassy, Law enforcement/police department, nearest hospital/emergency medical facility, English speaking doctor or health care provider.Please reach out to the Study Abroad Coordinator at to include us in your pre-departure orientation. We will provide information on the mandatory insurance and some general safety information.
Date and time of the scheduled orientation. Click here to enter text.
Emergency Contact:Please provide the contact information you will give to the students/participants during your time abroad.Click here to enter text.
Travel information
Dates of travel:
Please include dates of travel outside of the Rolla area.
Start date: Click here to enter text.End date: Click here to enter text.
Countries and cities to be visited:If needed, attach additional pages.
Location 1:Click here to enter text.
Location 2:Click here to enter text.
Location 3:Click here to enter text.
Location 4:Click here to enter text.
Visa Requirements: Please list any Visa requirements for Country(ies) you will be visiting.You can find this information by visiting theU.S. Department of State (travel.state.gov)
Location 1:Click here to enter text.
Location 2:Click here to enter text.
Location 3:Click here to enter text.
Location 4:Click here to enter text.
Will Students and Faculty be traveling together or separately?Click here to enter text.
Please provide the location where students and faculty will meet if you are not traveling together:Click here to enter text.
On-site Travel: List travel plans during the program to include the mode of transportation. Examples are Charter bus with driver, public transportation such as trains or buses. Note: Program Directors are strongly discouraged from renting and driving vehicles.
On-site Travel 1:Click here to enter text.
On-site Travel 2:Click here to enter text.
On-site Travel 3:Click here to enter text.
On-site Travel 4:Click here to enter text.
Lodging arrangements:
Lodging arrangements: Please indicate the type (hotel, local host homes, university dorm, hostel, etc.)and name of lodging for each location. Include the address and phone number for each.
Location 1:Click here to enter text.
Location 2:Click here to enter text.
Location 3:Click here to enter text.
Location 4:Click here to enter text.
Program Directors must stay in the same lodging area as the students. Please check the box to confirm.
☐ Yes, Program Directors will be staying at the same lodging area.
Location Specific Information
Embassy: Please provide the address and contact phone number for the nearest Embassy for each location.
Location 1:Click here to enter text.
Location 2:Click here to enter text.
Location 3:Click here to enter text.
Location 4:Click here to enter text.
911 Equivalent: Please list the number you will dial in case of an emergency.
Location 1:Click here to enter text.
Location 2:Click here to enter text.
Location 3:Click here to enter text.
Location 4:Click here to enter text.
Local Law Enforcement:Please provide the physical address, and phone number of local law enforcement or agency where crimes are to be reported for the areas you will be visiting. This information can typically be found on the Embassy or Consulate website for the location you are visiting.
Location 1:Click here to enter text.
Location 2:Click here to enter text.
Location 3:Click here to enter text.
Location 4:Click here to enter text.
Hospital: Please list the name, address and if possible a phone number for the nearest hospital to each of the locations you will visit.
Location 1:Click here to enter text.
Location 2:Click here to enter text.
Location 3:Click here to enter text.
Location 4:Click here to enter text.
Health & Safety: Please describe any health, safety or security considerations related to the location(s) you are going and how they may impact the program. You may wish to review information from the U.S. Department of State (travel.state.gov) and the Centers for Disease Control and Prevention (cdc.org)
Click here to enter text.
Required vaccinations: Please list any required vaccinations for any of the locations your program participants will be visiting.
Click here to enter text.
Activities
Please provide a list of activities and the safety precautions in place for each activity. Note: Some activities may require a separate or additional liability release form from each participant. If you have more than 4 activities planned, please include the information as an attachment to this document.
Activity 1:Click here to enter text.
Activity 2:Click here to enter text.
Activity 3:Click here to enter text.
Activity 4:Click here to enter text.
Insurance
The Curators of the University of Missouri have partnered with United Healthcare Global (formerly MEDEX) to provide 24/7 travel, medical, and security-related assistance to faculty, staff, and students while traveling more than 100 miles away from home or outside of their home country. Please note this is NOT medical insurance. More information, including a list of benefits and instructions for registration, can be found HERE.
Students Medical Insurance:
Students traveling internationallyfor a university-related trip or course are required to purchase travel health insurance through GeoBlue. For current cost please check with the Study Abroad Coordinator or visit our webpage, Traveling on Behalf of S&T.
Faculty & Staff:
The University of Missouri provides travel insurance for faculty members and staff members who travel on university business. Information about this coverage is available online on the UM System under International Travel. Please read all of the information provided in order to make an informed decision about your insurance needs.
It is recommended that faculty or staff members traveling with one or more students purchase the travel health insurance through GeoBlueso that all participants have the same coverage.Instructions for purchasing the insurance is available online in the GeoBlue Student Member Guide. Insurance may be purchased online, a code will be provided to you at the Pre-Departure orientation.
The office of International and Cultural Affairs employs an insurance specialist who can assist you with your travel insurance needs. Please email or call extension 6875 for more information.
Clery Reporting
Missouri S&T is required to report crime statistics for any location where a student stays for more than 1 night outside of Rolla on a university sponsored trip. Faculty or staff members are required to submit the report. Information must be reported for locations within the U.S. as well as international locations. This report will be turned in directly to the University Police Department, not to International & Cultural Affairs.
Please include the following in your report:
•Date(s) of stay
•Hotel information – hotel name, address, and room number or floor that was occupied
•Facility information for any location rented by the University for class study or program use – name and address
•Local law enforcement information – name and address
A reporting form will soon be added to the University Police web page - - under Programs and Services. Until the online form is available, please send information or questions to:
Mary Watkins, Compliance Coordinator, University Police
E-mail:
Phone: 573-341-6735
Program Director Signature: ______
Program Director Signature: ______
Dean’s Office Approval:
Printed Name: ______Date: ______
Signature: ______Date: ______
For use by the Office of International and Cultural Affairs / Study Abroad:
Reviewed by Study Abroad Advisory Committee: ______
OICA Approval: ______Date: ______
Faculty-led program Form 3
Last updated Tuesday, September 18, 2018Page 1