01 fam 0010

3 FAH-1 H-3740

EMERGENCY VISITATION TRAVEL (EVT)

(CT:POH-153; 06-22-2012)
(Office of Origin: HR/ER/WLD)

3 FAH-1 H-3741 emergency visitation travel (EVT) procedures

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. The subchapter is designed to:

(1) Be used in conjunction with the regulations published in 3 FAM 3740;

(2) Provide guidance for the preparation of emergency visitation travel (EVT) requests and authorizations;

(3) Achieve uniformity throughout the Department in preparing and routing EVT requests and authorizations; and

(4) Facilitate the provision of complete, accurate, and current personnel data for the EVT record system.

b. The subchapter lists the procedures for the five categories of emergency visitation travel (EVT): Medical; death; eldercare; unusual personal hardship; and unaccompanied post EVT. For clarification of specific terminology, see 3 FAM 3745, Definitions.

c. EVT benefits apply to the employee or spouse or domestic partner (as defined in 3 FAM 1610) who is directly related to the ill or deceased family member. However, the employee submits the required documentation on his or her own behalf and on behalf of the spouse or domestic partner (as defined in 3 FAM 1610). In keeping with the emergency nature of the EVT benefit, travel should always commence as soon as possible.

d. If it is determined that EVT authorization requirements were not met after all documentation has been submitted to the authorizing office, the authorization will be revoked, or in the case of a request for reimbursement, the expenses incurred by the traveler will not be reimbursed by post. Any disbursement of funds will be subject to collection as an overpayment per 4 FAM 490, Debt Collection (State), Automated Directive System Chapter 625 (USAID), and other agencies’ regulations on this issue.

e. The 3 FAH-1 Exhibit H-3741(1), EVT Benefits, describes emergency visitation travel (EVT) benefits, including eligible travelers, visitation objectives, limitations, and actions required by the employee.

f. The 3 FAH-1 Exhibit H-3741(2), Agency EVT Authorizing and Report Offices, provides a list of the relevant agency offices for all categories of EVT.

3 FAH-1 H-3742 Medical emergency visitation travel

3 FAH-1 H-3742.1 Authorization Procedures for Medical EVT

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. When an employee or spouse or domestic partner (as defined in 3 FAM 1610) learns that an immediate family member is seriously ill or injured and may be facing imminent death, the employee requests medical EVT authorization on behalf of the traveler.

b. Upon receiving the employee’s request, post:

(1) Informs employee of the process requirements (see 3 FAH-1 Exhibit H-3742.1, Required Medical EVT Documentation); and

(2) Contacts Office of Medical Services, Foreign Programs (MED/FP), via cable to request that MED confirm medical status of the immediate family member to be visited pursuant to the requirements of 3 FAM 3746.1. The cable should include required medical documentation. Outside of Washington, DC's business hours and on weekends, post should contact the Operations Center by phone (202 647-1512).

c. MED contacts the family member’s physician or hospital using the information provided in the cable. Post’s medical office or health unit is not involved in the medical EVT process; however, if the immediate family member is outside of the United States, MED contacts the closest mission health unit (HU) and requests that the HU obtain the required information pertaining to the family member’s medical status. The health unit reports the findings to the Office of Medical Services. Upon review of the findings, MED responds to post by cable that the family member’s illness does or does not meet the criteria for medical EVT as listed in 3 FAM 3746.1. If criteria are met, MED recommends that post authorize medical EVT.

d. Post HR subsequently approves or disapproves medical EVT requests. NOTE: Post cannot authorize a medical EVT request until MED has issued the recommendation.

e. All post-approved medical EVTs must be reported to the employee’s agency. A template for this report is included in 3 FAH-1 Exhibit H-3742.1, Required Medical EVT Documentation (also see 3 FAH-1 Exhibit H-3741(2), Agency EVT Authorizing and Reporting Offices).

3 FAH-1 H-3742.2 Employee Responsibilities in Medical EVT Process

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. Under the Health Insurance Portability Accountability Act (HIPAA), regulations at 45 CFR Parts 160 and 164, health care providers generally will not release patient information to MED unless authorized by the patient or a legal representative. Therefore, the patient or a designated personal representative must authorize the attending physician or hospital to release the patient’s information to MED using an Authorization for Release of Medical Information (suggested template is located in 3 FAH-1 Exhibit H-3742.1, Required Medical EVT Documentation). Other formats may be used for HIPAA authorizations, and an employee or spouse or domestic partner (as defined in 3 FAM 1610) will need to defer to the hospital or other health care provider if they have particular policies or procedures regarding the release of medical information; the language that must be included in a valid authorization under HIPAA is listed under 45 CFR 164.508(c). The determination of “personal representative” under HIPAA is governed by 45 CFR 164.502(g). The patient or personal representative must sign and date a HIPAA-compliant authorization, and send it to the family member’s physician or hospital in order for MED to request patient information. Upon receipt of the authorization, the physician or hospital will be permitted to respond to MED’s request for patient information. This authorization is essential to the medical EVT process.

b. If MED is not able to contact the treating physician or hospital or if the care providers refuse to share necessary medical information about the immediate family member, MED cannot confirm the family member’s health status and will not recommend authorization of medical EVT to post. In this case, the patient or patient’s personal representative must identify and authorize another physician to release the medical information to MED and provide the physician’s contact information to MED, or direct other family members to do so.

3 FAH-1 H-3742.3 Procedures for Authorization After Travel for Medical EVT

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. The employee or eligible spouse or domestic partner (as defined in 3 FAM 1610) may elect to travel in advance of authorized medical EVT. An employee traveling in advance of medical EVT authorization must submit a Repayment Agreement prior to commencing travel, since the employee is requesting U.S. Government funds in order to travel or will later be seeking reimbursement by U.S. Government funds as an EVT benefit.

b. Upon receipt of the Repayment Agreement, post may procure transportation. Alternatively, the employee may make travel arrangements using personal funds and request reimbursement upon return to post. As in all cases of EVT reimbursement requests, travel must conform to all applicable U.S. Government regulations.

c. Within 30 days of return to post, the employee completes and submits the Request for Medical EVT Reimbursement form DS-6525 and provides a report from the attending physician or hospital describing the nature of the illness at the time of travel. Employee faxes documentation to MED/FP for review with a copy to post HR and to the employee’s agency if other than the Department of State, and confirmation that the employee has signed the Repayment Agreement. The employee or spouse or domestic partner (as defined in 3 FAM 1610) must supply MED with supplemental information upon request.

d. If the immediate family member recovered, despite expectations of his or her death, the attending physician or hospital's statement must confirm that imminent death was expected when the employee or spouse’s or domestic partner’s (as defined in 3 FAM 1610) medical EVT commenced.

e. MED determines whether or not the medical status of the family member satisfied the requirements of 3 FAM 3746.1 at the time of travel, and cables the determination to post.

f. If MED determines that an ill or injured parent’s status did not meet medical EVT criteria, the employee may request reimbursement of eldercare EVT (as long as the traveler has not already completed two eldercare EVT trips), by following the procedures listed in 3 FAH-1 H-3744.2, Procedures for Authorization After Travel for Eldercare EVT.

3 FAH-1 H-3742.4 Death of Family Member Being Visited

(CT:POH-139; 10-01-2009)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. If the immediate family member dies after the employee or spouse or domestic partner (as defined in 3 FAM 1610) commences medical EVT but before she or he returns to post, the medical EVT status remains unchanged.

b. If the immediate family member dies prior to the employee or spouse or domestic partner (as defined in 3 FAM 1610) commencing travel, the medical EVT request must be revised to death EVT. In this situation, post would approve and fund the death EVT pursuant to 3 FAM 3746.2.

3 FAH-1 H-3743 Death emergency visitation travel

3 FAH-1 H-3743.1 Procedures for Death EVT

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. When an employee or spouse or domestic partner (as defined in 3 FAM 1610) learns that an immediate family member has died, the employee requests death EVT on behalf of the traveler:

(1) The employee requesting EVT at U.S. Government expense must complete a Repayment Agreement prior to travel (3 FAH-1 Exhibit H-3743.1), whereupon post may proceed to make travel arrangements; and

(2) The employee must provide a Statement of Travel (3 FAH-1 Exhibit H-3743.1) to post human resources (HR) as soon as possible but not more than 30 calendar days after completion of travel.

b. Post HR cables the statement to HR/ER (State). See listing in 3 FAH-1 Exhibit H-3743.1, Death EVT Required Documentation, for the reporting offices of other agencies.

3 FAH-1 H-3743.2 Procedures for Reimbursement for Travel at Own Expense to Visit Sibling Who Subsequently Dies

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

In the event the employee or spouse or domestic partner (as defined in 3 FAM 1610) travels at personal expense to visit an ill or injured sibling, and the sibling dies within 45 calendar days of the traveler’s departure from post, the traveler may elect either of the following options:

(1) Reimbursement for the round-trip visitation travel already completed at personal expense. However, if the travel does not otherwise conform to all applicable U.S. Government travel regulations, reimbursement may only be provided up to the equivalent cost of round-trip travel which meets such requirements; or

(2) Authorized death emergency visitation travel for the subsequent interment of that sibling.

The employee submits a request for death EVT following the procedures listed in 3 FAH-1 H-3743.1, and indicates the reimbursement option selected.

3 FAH-1 H-3744 Eldercare emergency visitation travel

3 FAH-1 H-3744.1 Authorization Procedures for Eldercare EVT

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

When an employee or spouse or domestic partner (as defined in 3 FAM 1610) learns that a parent has suffered a temporary or permanent incapacitation, the employee requests eldercare EVT on behalf of the traveler:

(1) The employee submits a Repayment Agreement, Certification Statement, itinerary, and estimated or actual ticket costs (see 3 FAH-1 Exhibit H-3744.1, Eldercare EVT Required Documentation) to post prior to departure. The Certification Statement documents the details of the eldercare EVT request as consistent with the requirements of 3 FAM 3744, subparagraph a(3), and serves as evidence of eligibility;

(2) Post HR cables the request for eldercare EVT authorization to HR/ER (State), inserting the text of both the Certification Statement and Repayment Agreement and the itinerary and estimated or actual ticket costs in U.S. dollars into the body of the cable, noting "signatures on file at post." For employees of other agencies, post HR cables the home agency for action. See 3 FAH-1 Exhibit H-3741.1, Agency Authorizing and Reporting Offices, for the appropriate agency office designation;

(3) HR/ER (State) cables post with authorization or disapproval of eldercare EVT for State Department employees;

(4) Employee must voucher eldercare EVT expenses within 30 days of return to post; and

(5) Vouchering: post must submit a copy of the final ticket charges to be posted against the eldercare fund citation to HR/EX/BUD (State).

3 FAH-1 H-3744.2 Procedures for Authorization After Travel for Eldercare EVT

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

If the employee, spouse or domestic partner (as defined in 3 FAM 1610) determines that travel in advance of authorization is necessary, the same documentation (Certification Statement, Repayment Agreement, itinerary and round trip ticket costs) is required; however, the timeframe for submission differs:

(1) Prior to departure, the employee submits the Repayment Agreement to post. Post retains the document on file and procures transportation for the traveler at that time. Alternatively, the employee may choose to pay for EVT expenses and request reimbursement of eldercare EVT expenses upon return to post. As in all cases of EVT reimbursement requests, travel must conform to all applicable U.S. Government regulations. A Repayment Agreement is required in both instances since the employee is requesting U.S. Government funds as an EVT benefit;

(2) Within 30 days of completion of travel, the employee submits the Certification Statement to post. Post cables the request for eldercare EVT (or Request for Reimbursement of eldercare EVT) Authorization, inserting the text of both the Certification Statement and Repayment Agreement and noting "signatures on file at post" to HR/ER (State). For employees of other agencies, see 3 FAH-1 Exhibit H-3741.1, Agency Authorizing and Reporting Offices, for the appropriate agency office designation for addressing the cable;

(3) HR/ER (State) subsequently cables post with authorization or disapproval of eldercare EVT at U.S. Government expense;

(4) Employee must file the travel voucher for the EVT within 30 days of return to post; and

(5) Vouchering: post must submit a copy of the final ticket charges to be posted against the eldercare fund citation to HR/EX/BUD (State).

3 FAH-1 H-3744.3 Death of Parent During Eldercare EVT Visit

(CT:POH-139; 10-01-2009)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. If the parent dies after the employee or spouse or domestic partner (as defined in 3 FAM 1610) commences eldercare EVT but before she or he returns to post, the eldercare EVT status remains unchanged.

b. If the parent dies prior to the employee or spouse or domestic partner (as defined in 3 FAM 1610) commencing travel, the eldercare EVT request must be revised to death EVT. In this situation, post would approve and fund the death EVT pursuant to 3 FAM 3746.2.

3 FAH-1 H-3745 Unusual Personal Hardship emergency visitation travel

3 FAH-1 H-3745.1 Procedures for Unusual Personal Hardship EVT

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

When an employee or spouse or domestic partner (as defined in 3 FAM 1610) is notified of an immediate family member's exceptional emergency which cannot be addressed by the previously named categories, the employee requests unusual personal hardship EVT on behalf of the traveler. Unusual personal hardship EVT criteria are stringent and requests are evaluated on a case-by-case basis:

(1) An employee requesting unusual personal hardship EVT submits a Repayment Agreement and a Certification Statement (see 3 FAH-1 Exhibit H-3745.1, Unusual Personal Hardship EVT Required Documentation) detailing the exceptional circumstances under which such a request is made, certifying the emergency nature and the personal hardship of the situation, and including any available documentation, medical and family contacts relating to the request;

(2) Post HR cables the request for unusual personal hardship EVT authorization, including the text of both the Certification Statement and Repayment Agreement in the cable and noting "signatures on file at post" to HR/ER (State). For employees of other agencies, see 3 FAH-1 Exhibit H-3741.1, Agency Authorizing and Reporting Offices, for the appropriate agency office designation for addressing the cable); and

(3) HR/ER (State) evaluates each request on a case-by-case basis and responds to post accordingly.

3 FAH-1 H-3745.2 Procedures for Authorization After Travel for Unusual Personal Hardship EVT

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

If the employee or spouse or domestic partner (as defined in 3 FAM 1610) determines that travel in advance of authorization is necessary, the same documents, Certification Statement and Repayment Agreement are required; however, the timeframe for submission differs:

(1) The employee submits a Repayment Agreement prior to departure. Post retains the document on file and procures transportation for the traveler at that time. Alternatively, the employee may choose to pay for EVT expenses, and request reimbursement of unusual personal hardship EVT expenses upon return to post. As in all cases of EVT reimbursement requests, travel must conform to all applicable U.S. Government regulations. A Repayment Agreement is required in both instances since the employee is requesting U.S. Government funds as an EVT benefit;

(2) The employee completes the Certification Statement within 30 calendar days after completion of travel;

(3) Post HR cables the request for unusual personal hardship EVT (or Request for Reimbursement of unusual personal hardship EVT) Authorization, including the text of both the Certification Statement and Repayment Agreement in the cable (3 FAH-1 Exhibit H-3745.1, Unusual Personal Hardship Required Documentation, and noting "signatures on file at post" to HR/ER (State). See 3 FAH-1 Exhibit H-3741.1, Agency Authorizing and Reporting Offices, for the appropriate agency office designation to use for the cable address; and

(4) HR/ER (State) evaluates each request on a case-by-case basis, and responds to post accordingly.

3 FAH-1 H-3746 procedures for UnACCOMPANIED PoST emergency visitation travel

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. When an employee at an unaccompanied post is critically ill or injured and a family member and/or agent’s presence is medically required:

(1) The Foreign Service medical provider (FSMP) initiates medevac action to move the patient to a medevac site;

(2) The FSMP is responsible for notifying the HRO or MO of the determination that criteria for unaccompanied post EVT have been met. In the FSMP's absence, the HRO in consultation with the RMO determines that the criteria for unaccompanied post EVT have been met;

(3) Post HR notifies the Office of Casualty Assistance (HR/OCA) (State) by phone of the request for unaccompanied post EVT for the employee. During EST nonbusiness hours, the emergency call to HR/OCA is routed through the Operations Center (202 647-1512). See Exhibit H-3741-2 for other Foreign Affairs agencies’ emergency offices;

(4) FSMP cables the medevac request referencing the determination of unaccompanied post EVT to the regional medevac center and MED/FP; and

(5) Post HR issues a followup cable to HR/OCA with information copies to HR/ER and the regional bureau. The cable includes the employee's name, location and date of emergency and references the FSMP's determination of unaccompanied post EVT. The cable must be sent with Priority delivery using "Sensitive" caption and paragraph markings and APER and AMED tags.

b. HR/OCA (State) makes the initial notification to the agent and/or designated family member(s) on file in the Employee’s Service Center, stating that a POC from HR/OCA will follow up with the agent and/or family member(s) to make the travel arrangements.

c. HR/OCA (State) in collaboration with the regional bureau issues the unaccompanied post EVT authorization with relevant fiscal data for the traveler(s) included in the EVT. Authorized travelers may originate from more than one location. EVT travel orders are issued to EFMs (including EFMs serving as agents). Invitational travel orders are issued to agents and non-EFM family members. With the assistance of the Family Liaison Office (HR/FLO), HR/OCA arranges transportation including payment of the airfare and ensures that hotel and ground transportation arrangements have been made at the employee’s location for the traveler(s).

d. MED will monitor the employee-patient status, recommending per diem for an initial emergency visitation period of up to 30 days or to the date of repatriation, whichever is less. Where necessary, MED may certify the need to extend the emergency visitation period.

e. MED will advise post and HR/OCA of the end-point of the emergency visitation period.

f. HR/OCA reports finalized expenditures to the appropriate regional bureau.

g. See 3 FAM 3747, Charge to Leave, for leave information and 3 FAM 3748, Funding, for funding information.

3 FAH-1 H-3747 through H-3749 UNASSIGNED

3 FAH-1 EXHIBIT H-3741(1)
EMERGENCY VISITATION TRAVEL (EVT) BENEFITS

(CT:POH-145; 11-18-2010)
(State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

outline of evt benefits

This chart is an outline of emergency visitation travel (EVT) benefits, including eligible travelers, visitation objectives, limitations, and actions required by employee.

TRAVEL BENEFIT	WHO MAY TRAVEL	VISITATION OBJECTIVE	REQUIRED EMPLOYEE/ POST ACTIONS	LIMITATIONS OF EVT
Medical EVT (Serious illness or injury where death is imminent)	Employee or eligible spouse or domestic partner directly related to the ill family member.	To visit immediate family member seriously ill or injured and near death.	Employee or EFM faxes Authorization for Release of Patient Information to physician. Employee submits required medical information to post. Post cables request for recommendation for authorization to MED/FP.	Employees and their spouses or domestic partners are limited to one round trip for each serious illness or injury of each immediate family member.
Death EVT (Upon death of immediate family member)	Employee or eligible spouse or domestic partner directly related to the deceased.	To attend interment of immediate family member (includes siblings of employee or spouse or domestic partner).	Employee submits Repayment Agreement prior to travel; submits Statement of Travel to post within 30 days after completion of travel. Post cables Statement to HR/ER (State) or to appropriate reporting office for other agencies.	Only one round trip for employee or spouse or domestic partner may be taken in case of death of his or her immediate family member. Travel commences as soon as possible in keeping with emergency nature of EVT benefit.
Death EVT (Upon death of employee or eligible family member at post)	Employee AND eligible family members resident at post.	To accompany remains of deceased employee or eligible family member who dies abroad for interment.
Eldercare EVT	Employee or eligible spouse or domestic partner related to the parent needing assistance.	To assist parent suffering health breakdown that threatens current living arrangements.	Employee submits Repayment Agreement and Certification Statement. Post cables both documents to HR/ER (State) or to appropriate authorizing office of other agency.	Not to exceed two round trips for each eligible individual (the employee or the employee’s spouse or domestic partner). Travel commences as soon as possible.
Unusual Personal Hardship EVT	Employee or eligible spouse or domestic partner.	To assist family member under exceptional hardship circumstances.	Employee submits Repayment Agreement and Certification Statement. Post cables both documents to HR/ER (State) or to appropriate authorizing office of other agency.	Evaluated on a case-by-case basis.
Unaccompanied Post EVT	Family member or agent	To assist medevaced employee	FSMP determines that EVT criteria are met; HRO contacts authorizing office to make contact with designees.	Evaluated on a case-by-case basis.

evt benefits for eligible Employees Away From Post

This chart is a detailed summary of emergency visitation travel (EVT) eligibility for employees abroad.

FOR EMPLOYEES ASSIGNED ABROAD	EMERGENCY IN THE UNITED STATES	EMERGENCY ABROAD
At post	Yes	Yes, cost-construct NTE cost from post to employee‘s service separation residence address in United States.
On TDY from assigned post abroad (abroad or in United States)	Yes	Yes, cost-construct NTE cost from post to employee‘s service separation residence address in United States. Exception: Cost-construct is not required if the location of the person being visited is abroad due to the employee’s TDY assignment abroad.
On other official travel (R&R, HL)	Yes, cost-construct NTE cost from post to service separation residence address in United States. Exception: no eligibility if traveler is in same country as family member.	Yes, cost-construct NTE cost from post to service separation residence address in United States. Exception: No eligibility if traveler is in same country as family member.
On personal travel	Yes, cost-construct NTE cost from post to service separation residence address in United States. Exception: No eligibility if traveler is in same country as family member.	Yes, cost-construct NTE cost from post to service separation residence address in United States. Exception: No eligibility if traveler is in same country as family member.

3 FAH-1 EXHIBIT H-3741(2)
AGENCY EVT AUTHORIZING AND REPORTING OFFICES

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

AGENCY	MEDICAL EVT	ELDERCARE AND UNUSUAL PERSONAL HARDSHIP EVT AUTHORIZED BY	UNACCOM-PANIED POST EVT AUTHORIZED BY	DEATH EVT AUTHOR-IZED BY	DEATH EVT AND MEDICAL EVT REPORTS SENT TO
State	Authorized by post only upon recommen-dation by State Department Office of Medical Services.	HR/ER	HR/OCA	Post	HR/ER
USDA	Authorized by post only upon recommen-dation by State Department Office of Medical Services.	FAS, OFSO Deputy Administrator	FAS, OFSO Deputy Administrator	FAS, OFSO Deputy Administrator	FAS, OFSO Deputy Administrator
BBG	Authorized by post only upon recommen-dation by State Department Office of Medical Services.	Office of Human Resources, M/H	Office of Human Resources (OHR), Director	Office of Human Resources M/H	Office of Human Resources M/H
Commerce	Authorized by post only upon recommen-dation by State Department Office of Medical Services.	ITA/USFCS/ OFSHR	DAS/OIO; Funding provided by OFSHR	ITA/ USFCS/ OFSHR	ITA/USFCS/ OFSHR
USAID	Authorized by post only upon recommen-dation by State Department Office of Medical Services.	Chief, OHR/FSP or designee	Chief, OHR/FSP or designee	Post	OHR/FSP

3 FAH-1 EXHIBIT H-3742.1
REQUIRED MEDICAL EVT DOCUMENTATION

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

The following documents are required for authorization of medical EVT:

a. Sample Authorization for Release of Patient Information (employee or other family member must provide to care-provider in advance of cable request):

“I [insert name of patient or designated representative; contact information] hereby authorize [insert name of healthcare provider or facility] to share information regarding the diagnosis, prognosis and plan of care for (name and date of birth of patient) with the U.S. Department of State Office of Medical Services in Washington, DC for purposes of determining eligibility for U.S. Government-funded emergency visitation travel. This information may be shared by phone, in person, by email or other means of communication. This authorization will expire on [x date], and I understand that I may at any time prior to this date revoke this authorization by notifying [name of healthcare provider or facility] except to the extent action has already been taken in reliance thereon.”

b. Cables requesting medical EVT must be sent using "Sensitive" caption and paragraph markings and AMED and APER tags. Sample cable:

Subject: MED/FP - REQUEST FOR MEDICAL EVT [employee last name, first name], [agency]

(1) (SBU) Employee [name] requests that MED/FP confirm health status of [name of ill immediate family member and relationship: spouse or domestic partner as defined in 3 FAM 1610, child, parent] to the traveler [employee or spouse or domestic partner as defined in 3 FAM 1610] to determine if requested EVT meets the requirements of 3 FAM 3746.1. Employee confirms that family has given permission to physician and/or facility to share information about the immediate family member, with the Office of Medical Services.

(2) (SBU) Required information:

[Name, home address and date of birth of ill family member]

[Name and phone number of physician and hospital or hospice POC]

[Name and phone number of family contact person and relationship to traveler and immediate family member]

(3) (SBU) EVT Repayment Acknowledgement:
I, [Name], certify that I have read and understand 3 FAM 3740, and that all expenditures made by [Department of State, USDA, BBG, Commerce, or USAID] in connection with my emergency visitation travel [or emergency visitation travel of my eligible spouse or domestic partner as defined in 3 FAM 1610] [Name] shall be subject to collection as an overpayment in the event that approval of such travel is determined to be unwarranted under the provisions of 3 FAM 3740. If I do not repay these funds immediately upon demand, I understand that the U.S. Government may pursue collection of these funds through deductions from salary, allowances, lump-sum payments, or other authorized remedy. [Signed and dated original on file at post.]

(4) (U) Embassy/post POC: [name xxxxx@state.gov].

c. Sample cable for post to report post-approved medical EVT (all medical EVT’s subsequently approved by post must be reported to the reporting office of the employee’s agency):

SUBJECT: HR/ER - REPORT OF POST-APPROVED EVT REQUEST: [Employee last name, first name] [Agency]
REF: STATE xxxxxx [MED’s response/recommendation cable]

(1) (SBU) Post has received determination by MED that the medical status of the family member meets the requirements of 3 FAM 3746.1, and approves the medical EVT request for [employee name].

(2) (SBU) Fiscal data for travel charged to post-held funds:
[travel costs: $xxxxxx; fund cite xx-xxxxxx.x-xxxx-xxxxxxxxxx-xxxx-xxxx]

(3) (U) Embassy/post POC: [name xxxxx@state.gov].

3 FAH-1 EXHIBIT H-3743.1
REQUIRED DEATH EVT DOCUMENTATION

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

a. The following documents are required for death EVT:

(1) Repayment Acknowledgement:

[Employee submits this document to post prior to travel.]

“I, [name], certify that I have read and understand 3 FAM 3740, and that all expenditures made by [Department of State, USDA, BBG, Commerce, or USAID] in connection with my emergency visitation travel [or emergency visitation travel of my eligible spouse or domestic partner as defined in 3 FAM 1610] [name] shall be subject to collection as an overpayment in the event that approval of such travel is determined to be unwarranted under the provisions of 3 FAM 3740. If I do not repay these funds immediately upon demand, I understand that the U.S. Government may pursue collection of these funds through deductions from salary, allowances, lump-sum payments, or any other remedy.”

________________________________
[signature] [date] [typed name]

(2) Statement of travel:

Employee submits the statement of travel to post within 30 days of return; post subsequently cables the statement and the repayment agreement to HR/ER (State) or to other agencies’ reporting offices. Death EVT cables must be sent using "Sensitive" caption and paragraph markings and APER tag.

Employee’s statement of travel must include:

Employee’s name, whether the employee or spouse or domestic partner as defined in 3 FAM 1610 is the traveler

Name of the traveler, if different from employee

Name of the deceased and the date of death

Relationship of the traveler to the deceased and

Dates and destination of travel

b. Sample cable for death EVT:

Subject: HR/ER - STATEMENT OF TRAVEL FOR DEATH EVT [EMPLOYEE LAST NAME, FIRST NAME, AGENCY]

(1) (SBU) I, [employee name] certify that on [date] I [or my spouse or domestic partner as defined in 3 FAM 1610]: [name] traveled to [destination city and State] to attend the funeral of [name of deceased, date of death and relationship to traveler]. I [or my spouse or domestic partner as defined in 3 FAM 1610] returned to post on [date].

(2) (SBU) Repayment Acknowledgement: “I, [name], certify that I have read and understand 3 FAM 3740, and that all expenditures made by [Department of State, USDA, BBG, Commerce, or USAID] in connection with my emergency visitation travel [or emergency visitation travel of my eligible spouse or domestic partner as defined in 3 FAM 1610] [name] shall be subject to collection as an overpayment in the event that approval of such travel is determined to be unwarranted under the provisions of 3 FAM 3740. If I do not repay these funds immediately upon demand, I understand that the U.S. Government may pursue collection of these funds through deductions from salary, allowances, lump-sum payments, or other authorized remedy.” [Signed originals on file at post.]

(3) (U) Embassy/post POC: [name xxxxx@state.gov].

3 FAH-1 EXHIBIT H-3744.1
REQUIRED ELDERCARE EVT DOCUMENTATION

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

Requests for authorization of eldercare EVT must include the following documentation whether the requests are made before or after travel: Employee Certification Statement, Repayment Acknowledgement, itinerary and estimated or actual round trip cost of travel in U.S. dollars. The request cable must be sent using "Sensitive" caption and paragraph markings and APER tag.

a. Sample cable to request eldercare EVT:

Subject: HR/ER - REQUEST FOR ELDERCARE EVT AUTHORIZATION [EMPLOYEE LAST NAME, FIRST NAME, AGENCY]

(1) (SBU) Employee Certification Statement: “I [employee name], certify that it is necessary for me (or for my spouse or domestic partner as defined in 3 FAM 1610: name), to travel to the location of my [or eligible spouse’s or domestic partner’s as defined in 3 FAM 1610] parent [name], who resides at [complete address], in order to assist in procuring appropriate care or making new living arrangements due to recently discovered incapacity: _______________________________________. I have the following indications that my [or my eligible spouse’s or domestic partner’s as defined in 3 FAM 1610] parent may not be able to continue living independently: ____________________________. The purpose of my travel is: ______________________________. I hereby declare that if approved, this would be my [first/or second] eldercare trip at U.S. Government expense. [Signed originals on file at post.]

(2) (SBU) EVT Repayment Acknowledgement: “I, ([name], certify that I have read and understand 3 FAM 3740, and that all expenditures made by [Department of State, USDA, BBG, Commerce, or USAID] in connection with my emergency visitation travel [or emergency visitation travel of my eligible spouse or domestic partner as defined in 3 FAM 1610] [name] shall be subject to collection as an overpayment in the event that approval of such travel is determined to be unwarranted under the provisions of 3 FAM 3740. If I do not repay these funds immediately upon demand, I understand that the U.S. Government may pursue collection of these funds through deductions from salary, allowances, lump-sum payments, or other authorized remedy.” [Signed originals on file at post.]

(3) (SBU) Itinerary;
Estimated or actual roundtrip ticket cost in (US Dollars) XXXX.

(4) (U) Embassy/post POC: [name xxxxx@state.gov].

b. The certification statement must include the traveler’s EVT destination address whether it is a hospital or care facility or the parent’s home address. If the employee or spouse or domestic partner (as defined in 3 FAM 1610) is traveling to assist an individual who served “in place of a parent” other than a biological, step, or adoptive parent, the employee must provide a copy of documentation supporting the relationship, to post. The employee must include reference to this documentation being on file at post, within the certification statement.

3 FAH-1 EXHIBIT H-3745.1
REQUIRED UNUSUAL PERSONAL HARDSHIP EVT DOCUMENTATION

(CT:POH-145; 11-18-2010)
(Uniform State/Agriculture/BBG/Commerce/USAID)
(Applies to Foreign Service Employees)

Requests for authorization of unusual personal hardship EVT must include the following documentation whether the requests are made before or after travel: Employee Certification Statement and Repayment Acknowledgement. The request cable must be sent using "Sensitive" caption and paragraph markings and the APER tag.

Sample cable to request unusual personal hardship EVT:

Subject: HR/ER - REQUEST FOR UNUSUAL PERSONAL HARDSHIP EVT AUTHORIZATION (EMPLOYEE LAST NAME, FIRST NAME), (AGENCY)

(1) (SBU) Employee certification statement:

Details the exceptional circumstances under which such a request is made

Certifies the emergency nature of the situation

Includes any available documentation, medical, or family contacts relating to the request.

(3) (U) Embassy/post POC: [name xxxxx@state.gov].