0920-1318 Information Needed to Process Humanitarian or Emergency

REQUIREMENT FOR PROOF OF COVID-19 VACCINATION FOR NONCITIZEN, NONIMMIGRANT AIR PASSENGERS

Information Needed to Apply for Humanitarian Exemption or Exception_Clean

Noncitizen Nonimmigrant Air Passenger - Request Humanitarian or Emergency Exception to Proof of Vaccination Requirement

OMB: 0920-1318

Document [docx]
Download: docx | pdf

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 Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorAmber Stolp
File Modified0000-00-00
File Created2022-06-27

© 2024 OMB.report | Privacy Policy