Travel Risk Assessment

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Faculty/Staff/Student Name Faculty/Staff/Student Name First Last
Email
Program
Travel Destination(s)
Date(s) of Travel Date(s) of Travel / MM / DD YYYY

Fill out subsequent fields if multiple dates of travel.
Date(s) of Travel Date(s) of Travel / MM / DD YYYY

Fill out subsequent fields if multiple dates of travel.
Date(s) of Travel Date(s) of Travel / MM / DD YYYY
Activity
Event Venue(s)
Host University (where applicable)
Host University Address (where applicable) Host University Address (where applicable)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Dates of Exchange Program 鈥撀燚eparture Date Dates of Exchange Program 鈥撀燚eparture Date / MM / DD YYYY
Dates of Exchange Program 鈥撀燫eturn Date Dates of Exchange Program 鈥撀燫eturn Date / MM / DD YYYY
Residence for duration of exchange

Residence for duration of exchange On campus Off campus
If residence during exchange is off campus, please enter address If residence during exchange is off campus, please enter address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Note: The Risk Management Department may be in contact with you for additional information related to travel itinerary in order to provide as comprehensive an assessment as possible.

Personal information on this form is collected under the University of Winnipeg Act and 36(1)(b) of the Freedom of Information and Protection of Privacy Act for the purpose of generating a certificate of insurance. Personal information will be disclosed as necessary to the University鈥檚 insurer to generate the certificate of insurance, and to the Location Contact for the purpose of confirming insurance coverage. Personal information may also be disclosed as necessary in the event of an insurance claim. Questions regarding privacy may be directed to the Information and Privacy Officer, 515 Portage Avenue, Winnipeg, MB, R3B 2E9 or 204.988.7538.
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Travel Risk Assessment

Travel Risk Assessment

Please read carefully.