Instructions: Complete and Sign the Form at Least 30 Days Before Departure to

INTERNATIONAL TRAVEL EXPORT CONTROL FORM

(For UTMB’s Employees andStudents Traveling on Official UTMB Business or in Support of UTMB Related Activities)

Instructions: Complete and sign the form at least 30 days before departure to .

Traveler’s Name:
Departure Date: / Return Date:
Phone Number: / Email:
Department: / Administrator Name:
Part I: Foreign Destination
1. Country Destination:
2. Purpose of Travel:
Part II: UTMB Tangible Items
1. Will you take any biological or chemical materials? / Yes No
If yes, please describe:
2. Will you take any toxins, vaccines, pathogens or any related genetic elements thereof? / Yes No
If yes, please describe:
3. Will you take an UTMB laptop?
*If yes, please complete the TMP certification. / Yes No
4. Will you take any other UTMB equipment? / Yes No
If yes, please describe:
Part III: UTMB Technology
1. Will you disclose any UTMB information that is notavailable in the public domain to foreign nationals? / Yes No
2. Will you disclose any information that could (i) threaten U.S. national security; (ii) be used to cause harm to animals, humans, vegetation;or (iii) be used to weaponize items? / Yes No
3. Will you disclose any information, results, data obtained from an UTMB and U.S. military (e.g. DOD, DTRA, Army, Navy, Air Force) contract or grant that is not available in the public domain and is generally not accessible to the public?
*If yes, please provide a copy of the grant or contract. / Yes No
4. Will you share any UTMB-developed, non-commercial encryption software in source code or object code? / Yes No
Part IV: Traveler’s Certification
I, hereby, certify that I have read and understand the information provided regarding compliance with export laws and regulations. I understand that I could be personally liable if I unlawfully export or disclose export controlled items, information or technology to foreign nationals without prior approval. I have provided accurate and truthful information in responding to the questions listed above.
Traveler Signature: ______Date:______
*No typed signatures
Export Control Use Only
 Approved  Not Approved
ECO Initials: ______Date:______