Request Exemption on Urgent Humanitarian Basis

Information Necessary for Humanitarian Exemption Request Considerations

(Not to be turned into public facing form)

Collected from passenger(s) or submitter

1. For each passenger: Name (family name/surname, given name), Passport# + Nationality

2. Cell phone including country code of passenger or head of household if family unit

3. Email of passenger or head of household if family unit

4. US destination address

   1. Is US destination home address?

5. Departure date and flight itinerary, including any connecting flights

   1. Flight # Departure Date

6. Name of submitting entity if different from passenger

1. Name of company submitting on behalf of passenger(s)

2. Name of point of contact submitting on behalf of passenger(s)

3. Phone and email address for POC submitting exemption request on behalf of passenger(s)

7. Purpose of travel to the US (provide brief explanation of why urgent travel is needed and how travel will contribute to health and safety of passengers(s))

8. Justification for testing exemption (e.g. no testing available, unable to obtain test/result before required departure, impact on health and safety)

9. Documentation to support justification for test exemption (e.g. medical records or orders for medical evacuation):

10. Information regarding any other solutions that were sought prior to exemption request (e.g. flight changes, assistance for testing)

For Embassy or Consulate Assessment

11. Testing availability and timeliness of results

    1. Testing available Yes/No

    2. Timeliness of results Yes/No

12. Other relevant information for consideration