Novel Coronavirus (2019 n-CoV) Travel Reporting

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* 1. First Name

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* 2. Last Name

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* 3. What date did you leave China, South Korea, Japan, Italy, or Iran?

Date / Time

Date

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* 4. Are you feeling sick?

Yes

No

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* 5. Local Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number