0920-1318 Request Humanitarian Exemption to COVID-19 Test or Docum

Information Needed to Process Humanitarian or Emergency Testing Exemption
or Vaccination Exception
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Type of Humanitarian or emergency request
 Exemption from predeparture testing requirement
 Exception for requirement for Proof of being fully vaccinated
Name (family name/surname, given name)
Passport #
Nationality
Cell phone number (including country code) of passenger or head of household if family unit
Email address of passenger or head of household if family unit
US destination address
 Is US destination home address?
Flight itinerary, including any connecting flights
 Airline
 Flight #
 Departure airport and date of departure
 Arrival airport and date of arrival
Vaccination Status
 Fully Vaccinated
▪ Name of vaccine product (or products if a combination)
▪ Date of first dose
▪ Date of second dose (if a two-dose series)
▪ PDF or photograph of vaccination record
 NOT Fully Vaccinated
Purpose of travel to the US and a brief explanation of why urgent travel is needed
As applicable:
 Justification for humanitarian exemption for testing requirement (e.g., no testing available
where passenger is located)
 Justification for humanitarian or emergency exception to providing proof of being fully
vaccinated (e.g., vaccine availability, passenger ineligible for vaccine at location, insufficient
time to become fully vaccinated)
Documentation to support justification (e.g., medical records, orders for emergency evacuation):
Information regarding any other solutions that were sought prior to application (e.g., flight changes,
testing en route, assistance in obtaining testing/vaccination, etc.)