Information Needed to Process Humanitarian or Emergency Testing Exemption or Vaccination Exception
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)
Age
U.S. Citizen, U.S. National, Lawful Permanent Resident?
If no:
Nationality
Indicate Visa Type or if passenger has Electronic System for Travel Authorization (ESTA)
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
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.)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Amber Stolp |
| File Modified | 0000-00-00 |
| File Created | 2021-12-20 |