Travel Questionnaire

Demographics

Given Name

Last Name

Institute Status

Email Address

Mobile Phone Number

Please enter the number where you can be reached immediately, if necessary.

Visit Details

Which IAS school/program are you visiting?

Enter program name

Are you a...

Please explain

What is the nature of your visit?

How long are you planning to be on campus?

Current Location

Which city are you currently in?

Which state or country are you currently in?

Travel History

Please list all countries/cities abroad that you've been in during the last 14 days. Please include the United States in the table below.

Travel

Country	Date you were last in this country	If you are unable to provide the date, please explain why:	City	Other City	Other City	Other City
Country	Date you were last in this country	If you are unable to provide the date, please explain why:	City	Other City	Other City	Other City
Country	Date you were last in this country	If you are unable to provide the date, please explain why:	City	Other City	Other City	Other City
Country	Date you were last in this country	If you are unable to provide the date, please explain why:	City	Other City	Other City	Other City

Date you returned or plan to return to the United States

If you are unable to provide the date above, please explain why:

Please provide your Airline and Flight number (if known)

Date you returned or plan to return to campus

If you are unable to provide the date above, please explain why:

Additional Questions

Do you know of someone diagnosed with Coronavirus (COVID-19)?

Yes

No

Have you visited a healthcare facility abroad within the last 14 days?

Yes

No

If so, where?

Do you have symptoms of the Coronavirus (fever, cough, shortness of breath)?

Yes

No

Did you come into contact with anyone sick while you were abroad (or here in the US)?

Yes

No

Did you self-quarantine while abroad, or since you have returned to the US?

Yes

No

Did you receive the influenze vaccine (i.e., flu shot) this season (fall 2019-winter 2020)?

Yes

No

Thank you for completing this form.

We ask that you NOT come to campus until you have been notified that your visit has been officially approved.