===== PAGE 1 ===== XAVIER UNIVERSITY

Risk Management & Insurance (513) 745-2090

Rev. 06/23/2020

TYPE OF PARTICIPANT	TYPE OF EXPERIENCE		AOR and Release	Health History Form Required
XU STUDENTS XU FACULTY AND EMPLOYEES
XU STUDENTS XU FACULTY AND EMPLOYEES
	Ongoing Experience on- and off-campus	Clubs, Club Sports Teams, Intramural Sports, Fitness Classes, Academic Classes	AOR 101	includes full health history section in form
	Overnight Experience	Domestic and international travel --- Does not apply to destinations under a U.S. Dept of State Travel Warning --- Required if trip includes 5 or more overnight off-campus stays --- Otherwise only required for risky activity --- See Instructions	AOR 102	HHF 201 or 203 and HHF 202 (for international travel only)
	Overnight Experience Travel Warning	Applies to destinations under a U.S. Dept of State Travel Warning	AOR 102 TW prior approval required	HHF 201 or 203 and HHF 202 (for international travel only)
	Day Trip Experience	Defined as less than 24 hours --Only required for risky activity --- See Instructions	AOR 103	includes short health history section in form
	On-Campus Experience	Only required for risky activity --- See Instructions	AOR 104	includes short health history section in form
XU STUDENTS
	Student Internship Experience	Required for all student internship experiences	AOR 105	includes short health history section in form
	Student Professional Field Experience	Required for all student professional field experiences	AOR 106	includes short health history section in form
NON-XU INDIVIDUALS
	Non-XU 18 Years and Older Experience		AOR 107	includes short health history section in form
	Non-XU Under 18 Years Experience		AOR 108	includes full health history section in form
XU STUDENTS
	Travel To/From Xavier University	To be signed by individuals when boarding transportation provided by Xavier University	AOR 109
	Separation From Group Travel	See specific instructions for AOR 110	AOR 110 with specific instructions
HEALTH HISTORY FORMS
	Student Health History Form	Applies to ALL overnight travel domestic and international	HHF 201
	Student Health Screening Exam Form	Applies to ONLY international travel	HHF 202
	Faculty/Employee Health History Form	Applies to ALL overnight travel domestic and international	HHF 203
• If an outside organization has supplied an alternate form for your activity or group, you must contact RM&I. • Original signed forms should be carried by event organizer or group leader, or by the student if traveling alone. • The sponsoring office or department must keep one paper or electronic copy of completed signed forms on hand during the experience, and at conclusion of the experience must retain a copy of signed forms for two years. • Campus Police should keep one paper or electronic copy of completed signed forms during the experience. • RE-TYPING OF FORMS IS PROHIBITED WITHOUT PRIOR APPROVAL FROM RM&I OR GENERAL COUNSEL. • THESE FORMS ARE THE ONLY FORMS APPROVED BY XAVIER UNIVERSITY

THESE FORMS ARE THE ONLY FORMS APPROVED BY XAVIER UNIVERSITY.