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Fall 2021 Center for Education Abroad Travel Screening Questionnaire
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First Name
*
Last Name
*
Position/Title
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Email Address
*
What is your role within the University of Rochester as it relates to your travel?
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Faculty
Staff
Undergraduate Student
Graduate Student (non-medical)
Medical Student (Resident, Fellow)
Other
Other
What is your affiliation with Rochester (select School)
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School of Arts and Sciences
Simon School of Business
Hajim School of Engineering and Applied Sciences
Warner School of Education
School of Medicine and Dentistry
Eastman School of Music
School of Nursing
Not affiliated with Rochester (specify)
Not affiliated with Rochester (specify)
List any non-Rochester faculty or staff who will be part of this travel (if applicable): name, position, email address
Start Date of Travel
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+
End Date of Travel
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+
Location of Proposed Travel Destinations
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Upload a copy of your travel itinerary (optional)
What is the purpose of your travel?
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Artistic Performance
Athletic Team Trip
Business/Work
Conference
Internship
Research
Student Organization Trip
Study Abroad
Volunteer
Personal Leisure
Other
Other
If you are a faculty or staff member, will you be traveling with Rochester students?
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YES
NO
If yes: how many students total?
Will you be working with a third-party provider, receiving support from a local university, or collaborating with any organizations abroad?
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YES
NO
If yes: please provide specific details of those schools or organizations
Provide a brief explanation of your proposed travel
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Is this travel being partially or fully funded by the University of Rochester?
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Yes
No
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