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XAVIER UNIVERSITY

Risk Management & Insurance (513) 745-2090

TYPE OF PARTICIPANT TYPE OF EXPERIENCE AOR and Release Health History Form Required

Rev. 06/23/2020

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.