New York State Traveler Health Form

New York State Traveler Health Form
(One form per adult required. Children or other dependents traveling with you can be included with one adult.)
All individuals coming into New York from either a non-contiguous state or US territory or any other country, whether or not such person is a New York resident, are required to complete the traveler health form upon entering New York. States contiguous to New York are NJ, CT, PA, MA, and VT.
Date
MonthDayYear
Date
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Is Phone Number a Mobile Number?
YesNo
Alternate Number
Please enter a valid phone number.
Is Alternate Number a Mobile Number?
YesNo
Date of Birth
MonthDayYear
Date
Age
Name of Children Travelling With You*
Primary State of Residence
NYSOther
Date of Arrival
MonthDayYear
Date
In The Last 10 Days Have You Been In a State (not bordering NYS), US Territory, OR Another Country?
Yes-for more than 24 hoursYes-for 24 hours or lessNo
List state/country
Last date in state/country
MonthDayYear
Date
Other state/country
Last date in state/country
MonthDayYear
Date
Destination Address in New York State
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
County
Hotel Name
For New York residents, is final destination listed your primary residence?
YesNo
For non-New York State residents, duration of visit in NYS
How did you travel into New York? (select all that apply)
Private vehiclePublic TransportTrainAirplaneShipBus
Arrival Airport:
Airline:
Flight Number:
Seat Number:
TODAY OR IN THE PAST 24 HOURS, HAVE YOU HAD ANY OF THE FOLLOWING SYMPTOMS?
Yes No
Fever (100.4° F / 38° C or higher), felt feverish, or had chills?
Cough? (new or worsening)?
Difficulty breathing? (new or worsening)?
You will be called by a representative of the New York State Contact Tracing Program. Do you consent to receive messages via text? (If you do not consent to text, you will be called to clarify any information needed
YesNo
What is your primary language?
EnglishOther
VACCINATION STATUS
Have you had all of the required dose(s) of your vaccine?
YesNo
(2 doses for Moderna and Pfizer, 1 dose for Janssen/Johnson & Johnson)
Date of final dose
MonthDayYear
Date
RECOVERED FROM CONFIRMED COVID-19 ILLNESS
Have you previously been diagnosed as having COVID-19?
YesNo
If you had symptoms, date symptoms began:
MonthDayYear
Date
If you did not have symptoms, date of first positive diagnostic test
MonthDayYear
Date
QUARNATINE REQUIREMENTS AND RECOMMENDATIONS
- All New Yorkers, as well as those visiting from out of state, are required to comply with all COVID-19 safety measures including wearing face coverings, social distancing and avoiding group gatherings and vulnerable populations in the best interest of public health.
- Domestic Travelers: Asymptomatic domestic travelers arriving in New York State from other U.S. states and territories are not required to test or quarantine. Domestic travelers do not need to quarantine if they are fully vaccinated or have recovered from laboratory confirmed COVID-19 within the previous 3 months. However, while not required, quarantine is still recommended for all other asymptomatic domestic
  travelers for either 7 days with a test 3-5 days after travel or 10 days without a test.
- Symptomatic domestic travelers must self-isolate immediately and contact their health care provider or local health authority to determine if they should seek testing.
- International Travelers: Per CDC, all international travelers must quarantine for either 7 days with a test 3-5 days after travel, or quarantine for the full 10 days without a test. This requirement applies to all international travelers whether they were tested before boarding, are recovered from a previous COVID infection, or are fully vaccinated.
- Travelers from border states (NJ, CT, PA, MA, VT) are not required to quarantine. Non-essential travel is discouraged.
- All travelers, both domestic and international, must continue to monitor symptoms through day 14. If any symptoms develop, travelers should immediately self-isolate and contact their health care provider or local health authority to report this change and determine if they should seek testing.
- NYS does not grant exemptions from the travel advisory for international travel. For more information, international travelers should consult the CDC website.
- CDC provides limited exemptions for flight crews.
ADDITIONAL INFORMATION
For additional information regarding the NYS Travel Advisory visit: https://ny.gov/traveladvisory
Upon entering New York State, if you are a traveler and do not have a suitable dwelling for your quarantine period, you must find appropriate accommodations at your own cost. If you are a NYS resident returning from travel and do not have appropriate accommodations for quarantine, please call your local health department: www.health.ny.gov/contact/contact_information/
ATTESTATION
I hereby attest, under penalty of law, that all information that I have provided is true and accurate to the best of my knowledge.
Signature
Clear
Date
MonthDayYear
Date
Should be Empty:

	Yes	No
Fever (100.4° F / 38° C or higher), felt feverish, or had chills?
Cough? (new or worsening)?
Difficulty breathing? (new or worsening)?

New York State Traveler Health Form

VACCINATION STATUS

RECOVERED FROM CONFIRMED COVID-19 ILLNESS

QUARNATINE REQUIREMENTS AND RECOMMENDATIONS

ADDITIONAL INFORMATION

ATTESTATION