COVID-19 Out of State Travel Screening Form
This form aims to screen out of state travelers to prevent potential COVID-19 cases. All information provided will be used to assist in the State’s response to the COVID-19 Pandemic. Please complete the form questions accurately a day PRIOR to your arrival.
Full Name
Mr.
Mrs.
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Travel Information
Are you traveling alone?
Yes
No
Please list the companion travelers with you:
*
What transportation type will you use?
Train
Bus
Airplane
Ferry
Private vehicle
Other
Where will you be staying during your visit?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Arrival Date
-
Month
-
Day
Year
Date
Estimated Departure
-
Month
-
Day
Year
Date
COVID-19 Symptoms
Have you or any of those traveling with you tested positive for COVID-19 in the past 14 days?
Yes
No
Have you been in proximate contact in the past 14 days with anyone who has tested positive for COVID-19?
Yes
No
Are you or any of those traveling with you feeling sick?
Yes
No
Are you or any of those traveling with you have experienced any symptoms below?
Fever or chills
Cough
Shortness of breathe
Fatigue
Muscle or body aches
Headache
Loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
*
I confirm that the information provided by me is accurate, correct and complete
Signature
Clear
Submit
Should be Empty: