Please complete the individual travel information below
Name
*
First Name
Last Name
T-NO
*
Phone
*
Email
*
University Affiliation
*
Student
Faculty
Staff
Do you live in on-campus housing?
*
Yes
No
Are you planning on traveling or are you currently traveling outside the United States?
*
Yes
No
Where are you currently traveling or planning to travel? If other, please specify the location outside the United States.
*
Mainland China
Iran
Italy
South Korea
Japan
Is your travel for personal reasons or for University business/University-sponsored purpose?
*
Personal reasons
University business/university-sponsored purpose
Please describe your travel plans. Include U.S. departure and U.S. arrival dates and locations visited (city/country).
*
Departure Date
Return Date
City
Country
Are you intending to return to the University after your travel?
*
Yes
No
Are you aware that you must self-quarantine for 14 days prior to returning to the University if you have traveled to China, Iran, Italy, South Korea, Japan or any other country determined to be a Level 2 or Level 3 by the CDC?
*
Yes
No
Are you aware that you must notify the University before you return to campus after the 14-day self-quarantine by sending an email to healthservices@tsu.edu, and that you must receive written approval to return to campus?
*
Yes
No
Have you traveled to Mainland China, Iran, Italy, South Korea, Japan or any other international location since January 1, 2020?
*
Yes
No
If Yes, please describe where and when you traveled.
*
For faculty and staff, please identify a point of contact at the University: This may be your department chair or your supervisor.
*
Department
Email
Phone Number
Please identify an emergency contact outside the University
*
Name
Relationship
Email
Phone Number
Have you had any close contact with a family member or person who has recently traveled to countries on the CDC advisory list?
*
Yes
No
Have any of these individuals exhibited any symptoms of illness since they returned?
*
Yes
No
