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Thank you for filling out this form regarding your travel plans for the Spring. This information will be kept private and will only be shared on a need-to-know basis. NHTI will use this information to assess potential exposure to the Coronavirus (COVID-19) to keep our NHTI community healthy.

If you have or are planning to travel on multiple trips, please complete an individual survey form for each trip.

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* 1. Last Name

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* 2. First Name

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* 3. Best Contact Number

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* 4. NHTI Email Address

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* 5. Alternative Email

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* 6. I am from...

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* 7. I am

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* 8. I am an Allied Health major in...

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* 9. Major

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* 10. My living arrangements are...

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* 11. My classes are (check all that apply)

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* 12. My travel is....

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* 13. I have traveled to or plan to travel to...
(Travel to multiple locations, please list all locations using the 2nd and 3rd options below)

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* 14. Dates of Travel

Date
Date

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* 15. Mode of Travel (check all that apply)

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* 16. Airports (please include all connecting airports)

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* 17. Train/Bus Stations

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* 18. Ports

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* 19. Are you aware having been in any contact with an individual(s) with exposure with COVID-19?

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* 20. If yes...

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* 21. Additional Comments

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