Returning Travelers - Northwood University Forms

Northwood University students, faculty and staff who have traveled in the past 14 days are asked to fill out this form if their travel could have exposed them to the COVID-19 virus or if they think they have been exposed in other ways. The information collected will help University and state health officials prevent the spread of COVID-19 and maintain the health and safety of the University and our community.

Name *

First Last

Email *

Relationship to Northwood *

Traditional Residential Student
Adult Degree Program Student
DeVos Graduate School Student
Faculty
Staff
Visitor

What is your current location? *

City State / Province / Region Country

Has your travel been international, or domestic? *

International
Domestic

To which countries have you traveled in the last two weeks? *

To which cities have you traveled in the last two weeks? *

What date did you arrive/do you plan to arrive in the US? *

What date did you return/do you plan to return to campus? *

Were you in contact with anyone diagnosed with COVID-19? *

Yes
No
Not sure

Were you in contact with anyone you suspect may have had COVID-19? *

Yes
No
Not sure

Were you in contact with anyone who had any of these symptoms: fever, cough, and/or shortness of breath? *

Yes
No
Not sure

Do you currently have fever, cough, and/or shortness of breath? *

Yes
No

Please provide any other notes you think we need to know about your health or recent travels:

Email

This field is for validation purposes and should be left unchanged.