Student Travel Form

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UMPD Student Travel Form

Name

This field is for validation purposes and should be left unchanged.

Form Information & Instructions

Any University of Maine employee who leads a trip or program in which students are traveling is required to submit that information via this form for each trip or program. This is required for compliance with the the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (20 U.S.C. § 1092; 34 CFR 668.46), commonly known as the “Clery Act”.

The Clery Act requires that any University-sponsored trip or program involving students in which the institution has “control” over an accomodation or other physical used space used in conjunction with the trip or program be reported for crime statistics purposes. Information submitted via this form allows the Clery Compliance Coordinator determine if the University had control over the space and, if so, contact relevant law enforcement agencies for reports on incidents that may have occurred at those locations while the trip or program occurred.

Please note that Clery Act reporting is based on calendar year, not academic year. It is important that you submit information as soon as possible to ensure the proper assessment and follow-up can be condcted. For more information about this process, send an email the UMPD Clery Group (umpd-clery-group@maine.edu).

Trip/Program Group Information

Name of Trip/Program or Group(Required)

Department(Required)

Department or Office sponsoring the Trip/Program or Group

Trip or Program Leader (Employee) Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Title/Position(Required)

Department or Office sponsoring the Trip/Program or Group

Trip/Program Information

Please respond to the below-listed questions. If you utilized more than one facility for this trip, please complete a seperate form for each facility utilized.

Departure Date from UMaine(Required)

Return Date to UMaine(Required)

Name of Lodging or Other Facility(Required)

Department or Office sponsoring the Trip/Program or Group

Address of Lodging or Other Facility(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Check-In Date to the Facility(Required)

Check-Out Date to the Facility(Required)

Floors and/or Room Numbers Utilized within the Facility(Required)

Purpose of Using the aforementioned Facility?(Required)

e.g. Lodging for event, Instructional space, etc.)

How often does this trip/program occur?(Required)

One time

Once per semester

Once per year / annually

Other (include description below):

Description for "Other" selection from above:

If this trip/program occurs more than one time, do you?(Required)

Does this trip/program include any overnight side trips?(Required)

Are there any additional facilities that you utilized during this trip?(Required)

Full List of Attendees(Required)

Please include First Name, Last Name, UMS email, and status. Each individual should be listed on a separate line. (Examples: Susanne Smith, susanne.smith5@maine.edu, Student; Barbara Johansson, barbara.johansson@maine.edu, Faculty)

Acknowledgement

By signing this form, I attest that all of the information provided is true and accurate to the best of my knowledge. [Electronically sign by typing your full name below]

Name(Required)

First Last

University of Maine Police Department

81 Rangeley Road, Orono, ME 04469
um.policedepartment@maine.edu
Phone: 207.581.4040
Fax: 207.581.1702

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