0920-1318 Information Needed to Process Humanitarian or Emergency

Information Needed to Process Humanitarian or Emergency Vaccination Exception

1. Nationality of passport traveled on

2. Indicate Visa Type or if passenger has Electronic System for Travel Authorization (ESTA)

3. Name (family name/surname, given name)

4. Age

5. Cell phone number (including country code) of passenger or head of household if family unit (if available)

6. Email address where passenger or head of household if family unit can be reached

7. US destination address

   1. Is US destination home address?

8. Flight itinerary, including any connecting flights

   1. Airline

   2. Flight #

   3. Departure airport and date of departure

   4. Arrival airport and date of arrival

9. Any COVID-19 vaccines received to date, if applicable (list product name and date for each dose)

10. Purpose of travel to the US and a brief explanation of why urgent travel is needed

11. 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)

12. Documentation to support justification (e.g., medical records, orders for emergency evacuation):

13. Information regarding any other solutions that were sought prior to application (e.g., flight changes, testing en route, assistance in obtaining vaccination, etc.)