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PERSONAL TRAVEL INFORMATION DISCLOSURE FORM - Division of Academic Affairs
If you have recently traveled to any of the locations on CDC website (
https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html
), domestic or international, where cases of COVID-19 have been identified, please complete this form.
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Email
*
Your email
Name
*
Your answer
Email
*
Your answer
Position
*
Your answer
College/School or Unit
*
Your answer
Supervisor's Email Address
*
Your answer
Travel Location (Country/State/City)
*
Your answer
Date of Return
*
MM
/
DD
/
YYYY
Are you planning to exercise self-quarantine?
*
Yes
No
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