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Waiver Form Matrix

Xavier University Risk Management & Insurance  |  (513) 745-2090  |  Rev. 06/23/2020

Xavier University Waiver Form Matrix
Type of Participant Type of Experience AOR and Release Health History Form Required
XU Students, Faculty, and Employees Ongoing Experience
On- and off-campus

Clubs, Club Sports Teams, Intramural Sports, Fitness Classes, Academic Classes		 AOR 101 AOR 101 includes full health history section in form.
Overnight Experience
Domestic and international travel

Does not apply to destinations under a U.S. Department 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. Department 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 AOR 103 includes short health history section in form.
On-Campus Experience
Only required for risky activity — see Instructions.		 AOR 104 AOR 104 includes short health history section in form.
Student Internship Experience
Required for all student internship experiences.		 AOR 105 AOR 105 includes short health history section in form.
Student Professional Field Experience
Required for all student professional field experiences.		 AOR 106 AOR 106 includes short health history section in form.
Non-XU Individuals Non-XU 18 Years and Older Experience AOR 107 AOR 107 includes short health history section in form.
Non-XU Under 18 Years Experience AOR 108 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

Important Information

  • If an outside organization has supplied an alternate form for your activity or group, you must contact Risk Management & Insurance (RM&I).
  • Original signed forms should be carried by the 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 the 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.