Travel Questionnaire

Demographics
Please enter the number where you can be reached immediately, if necessary.
Visit Details
Which IAS school/program are you visiting?
Are you a...
Current Location
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. 

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
Additional Questions
Do you know of someone diagnosed with Coronavirus (COVID-19)?
Have you visited a healthcare facility abroad within the last 14 days?
Do you have symptoms of the Coronavirus (fever, cough, shortness of breath)?
Did you come into contact with anyone sick while you were abroad (or here in the US)?
Did you self-quarantine while abroad, or since you have returned to the US?
Did you receive the influenze vaccine (i.e., flu shot) this season (fall 2019-winter 2020)?