First Name* must provide value
Last Name* must provide value
Position/Classification* must provide value
Student Faculty Resident/Fellow EVMS Staff
Involved in Direct Patient Care?* must provide value
Yes
No
Department
Educational Program
Phone number (Best)* must provide value
Email
Direct Supervisor or Program/Instructor: Name* must provide value
Direct Supervisor or Program/Instructor: Email* must provide value
Have you traveled domestically or internationally in the last 2 weeks?* must provide value
Yes
No
How did you travel?* must provide value
Car
Plane
Cruise ship or riverboat
Train
Bus
Other
Car
Plane
Cruise ship or riverboat
Train
Bus
Other
Did you have a layover?* must provide value
Yes
No
Travel Table AC - Ascension Island AD - Andorra AE - United Arab Emirates AF - Afghanistan AG - Antigua and Barbuda AI - Anguilla AL - Albania AM - Armenia AN - Netherlands Antilles AO - Angola AQ - Antarctica AR - Argentina AS - American Samoa AT - Austria AU - Australia AW - Aruba AX - Åland Islands AZ - Azerbaijan BA - Bosnia and Herzegovina BB - Barbados BD - Bangladesh BE - Belgium BF - Burkina Faso BG - Bulgaria BH - Bahrain BI - Burundi BJ - Benin BL - Saint Barthélemy BM - Bermuda BN - Brunei BO - Bolivia BQ - British Antarctic Territory BR - Brazil BS - Bahamas BT - Bhutan BV - Bouvet Island BW - Botswana BY - Belarus BZ - Belize CA - Canada CC - Cocos [Keeling] Islands CD - Congo - Kinshasa CD - Congo [DRC] CF - Central African Republic CG - Congo - Brazzaville CG - Congo [Republic] CH - Switzerland CI - Côte d'Ivoire CI - Ivory Coast CK - Cook Islands CL - Chile CM - Cameroon CN - China CO - Colombia CP - Clipperton Island CR - Costa Rica CS - Serbia and Montenegro CT - Canton and Enderbury Islands CU - Cuba CV - Cabo Verde CX - Christmas Island CY - Cyprus CZ - Czech Republic DE - Germany DG - Diego Garcia DJ - Djibouti DK - Denmark DM - Dominica DO - Dominican Republic DZ - Algeria EA - Ceuta and Melilla EC - Ecuador EE - Estonia EG - Egypt EH - Western Sahara ER - Eritrea ES - Spain ET - Ethiopia FI - Finland FJ - Fiji FK - Falkland Islands FK - Falkland Islands [Islas Malvinas] FM - Micronesia FO - Faroe Islands FQ - French Southern and Antarctic Territories FR - France FX - Metropolitan France GA - Gabon GB - United Kingdom GD - Grenada GE - Georgia GF - French Guiana GG - Guernsey GH - Ghana GI - Gibraltar GL - Greenland GM - Gambia GN - Guinea GP - Guadeloupe GQ - Equatorial Guinea GR - Greece GS - South Georgia and the South Sandwich Islands GT - Guatemala GU - Guam GW - Guinea-Bissau GY - Guyana HK - Hong Kong HM - Heard Island and McDonald Islands HN - Honduras HR - Croatia HT - Haiti HU - Hungary IC - Canary Islands ID - Indonesia IE - Ireland IL - Israel IM - Isle of Man IN - India IO - British Indian Ocean Territory IQ - Iraq IR - Iran IS - Iceland IT - Italy JE - Jersey JM - Jamaica JO - Jordan JP - Japan JT - Johnston Island KE - Kenya KG - Kyrgyzstan KH - Cambodia KI - Kiribati KM - Comoros KN - Saint Kitts and Nevis KP - North Korea KR - South Korea KW - Kuwait KY - Cayman Islands KZ - Kazakhstan LA - Laos LB - Lebanon LC - Saint Lucia LI - Liechtenstein LK - Sri Lanka LR - Liberia LS - Lesotho LT - Lithuania LU - Luxembourg LV - Latvia LY - Libya MA - Morocco MC - Monaco MD - Moldova ME - Montenegro MF - Saint Martin MG - Madagascar MH - Marshall Islands MI - Midway Islands MK - Macedonia MK - Macedonia [FYROM] ML - Mali MM - Myanmar [Burma] MN - Mongolia MO - Macau SAR China MO - Macau MP - Northern Mariana Islands MQ - Martinique MR - Mauritania MS - Montserrat MT - Malta MU - Mauritius MV - Maldives MW - Malawi MX - Mexico MY - Malaysia MZ - Mozambique NA - Namibia NC - New Caledonia NE - Niger NF - Norfolk Island NG - Nigeria NI - Nicaragua NL - Netherlands NO - Norway NP - Nepal NQ - Dronning Maud Land NR - Nauru NU - Niue NZ - New Zealand OM - Oman PA - Panama PC - Pacific Islands Trust Territory PE - Peru PF - French Polynesia PG - Papua New Guinea PH - Philippines PK - Pakistan PL - Poland PM - Saint Pierre and Miquelon PN - Pitcairn Islands PR - Puerto Rico PS - Palestinian Territories PT - Portugal PU - U.S. Miscellaneous Pacific Islands PW - Palau PY - Paraguay PZ - Panama Canal Zone QA - Qatar QO - Outlying Oceania RE - Réunion RO - Romania RS - Serbia RU - Russia RW - Rwanda SA - Saudi Arabia SB - Solomon Islands SC - Seychelles SD - Sudan SE - Sweden SG - Singapore SH - Saint Helena SI - Slovenia SJ - Svalbard and Jan Mayen SK - Slovakia SL - Sierra Leone SM - San Marino SN - Senegal SO - Somalia SR - Suriname ST - São Tomé and Príncipe SV - El Salvador SY - Syria SZ - Swaziland TA - Tristan da Cunha TC - Turks and Caicos Islands TD - Chad TF - French Southern Territories TG - Togo TH - Thailand TJ - Tajikistan TK - Tokelau TL - Timor-Leste TL - East Timor TM - Turkmenistan TN - Tunisia TO - Tonga TR - Turkey TT - Trinidad and Tobago TV - Tuvalu TW - Taiwan TZ - Tanzania UA - Ukraine UG - Uganda UM - U.S. Minor Outlying Islands US - United States UY - Uruguay UZ - Uzbekistan VA - Vatican City VC - Saint Vincent and the Grenadines VD - North Vietnam VE - Venezuela VG - British Virgin Islands VI - U.S. Virgin Islands VN - Vietnam VU - Vanuatu WF - Wallis and Futuna WK - Wake Island WS - Samoa YD - People's Democratic Republic of Yemen YE - Yemen YT - Mayotte ZA - South Africa ZM - Zambia ZW - Zimbabwe DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Date of Arrival
M-D-Y
Date of Departure
M-D-Y
Add Another Location +
AC - Ascension Island AD - Andorra AE - United Arab Emirates AF - Afghanistan AG - Antigua and Barbuda AI - Anguilla AL - Albania AM - Armenia AN - Netherlands Antilles AO - Angola AQ - Antarctica AR - Argentina AS - American Samoa AT - Austria AU - Australia AW - Aruba AX - Åland Islands AZ - Azerbaijan BA - Bosnia and Herzegovina BB - Barbados BD - Bangladesh BE - Belgium BF - Burkina Faso BG - Bulgaria BH - Bahrain BI - Burundi BJ - Benin BL - Saint Barthélemy BM - Bermuda BN - Brunei BO - Bolivia BQ - British Antarctic Territory BR - Brazil BS - Bahamas BT - Bhutan BV - Bouvet Island BW - Botswana BY - Belarus BZ - Belize CA - Canada CC - Cocos [Keeling] Islands CD - Congo - Kinshasa CD - Congo [DRC] CF - Central African Republic CG - Congo - Brazzaville CG - Congo [Republic] CH - Switzerland CI - Côte d'Ivoire CI - Ivory Coast CK - Cook Islands CL - Chile CM - Cameroon CN - China CO - Colombia CP - Clipperton Island CR - Costa Rica CS - Serbia and Montenegro CT - Canton and Enderbury Islands CU - Cuba CV - Cabo Verde CX - Christmas Island CY - Cyprus CZ - Czech Republic DE - Germany DG - Diego Garcia DJ - Djibouti DK - Denmark DM - Dominica DO - Dominican Republic DZ - Algeria EA - Ceuta and Melilla EC - Ecuador EE - Estonia EG - Egypt EH - Western Sahara ER - Eritrea ES - Spain ET - Ethiopia FI - Finland FJ - Fiji FK - Falkland Islands FK - Falkland Islands [Islas Malvinas] FM - Micronesia FO - Faroe Islands FQ - French Southern and Antarctic Territories FR - France FX - Metropolitan France GA - Gabon GB - United Kingdom GD - Grenada GE - Georgia GF - French Guiana GG - Guernsey GH - Ghana GI - Gibraltar GL - Greenland GM - Gambia GN - Guinea GP - Guadeloupe GQ - Equatorial Guinea GR - Greece GS - South Georgia and the South Sandwich Islands GT - Guatemala GU - Guam GW - Guinea-Bissau GY - Guyana HK - Hong Kong HM - Heard Island and McDonald Islands HN - Honduras HR - Croatia HT - Haiti HU - Hungary IC - Canary Islands ID - Indonesia IE - Ireland IL - Israel IM - Isle of Man IN - India IO - British Indian Ocean Territory IQ - Iraq IR - Iran IS - Iceland IT - Italy JE - Jersey JM - Jamaica JO - Jordan JP - Japan JT - Johnston Island KE - Kenya KG - Kyrgyzstan KH - Cambodia KI - Kiribati KM - Comoros KN - Saint Kitts and Nevis KP - North Korea KR - South Korea KW - Kuwait KY - Cayman Islands KZ - Kazakhstan LA - Laos LB - Lebanon LC - Saint Lucia LI - Liechtenstein LK - Sri Lanka LR - Liberia LS - Lesotho LT - Lithuania LU - Luxembourg LV - Latvia LY - Libya MA - Morocco MC - Monaco MD - Moldova ME - Montenegro MF - Saint Martin MG - Madagascar MH - Marshall Islands MI - Midway Islands MK - Macedonia MK - Macedonia [FYROM] ML - Mali MM - Myanmar [Burma] MN - Mongolia MO - Macau SAR China MO - Macau MP - Northern Mariana Islands MQ - Martinique MR - Mauritania MS - Montserrat MT - Malta MU - Mauritius MV - Maldives MW - Malawi MX - Mexico MY - Malaysia MZ - Mozambique NA - Namibia NC - New Caledonia NE - Niger NF - Norfolk Island NG - Nigeria NI - Nicaragua NL - Netherlands NO - Norway NP - Nepal NQ - Dronning Maud Land NR - Nauru NU - Niue NZ - New Zealand OM - Oman PA - Panama PC - Pacific Islands Trust Territory PE - Peru PF - French Polynesia PG - Papua New Guinea PH - Philippines PK - Pakistan PL - Poland PM - Saint Pierre and Miquelon PN - Pitcairn Islands PR - Puerto Rico PS - Palestinian Territories PT - Portugal PU - U.S. Miscellaneous Pacific Islands PW - Palau PY - Paraguay PZ - Panama Canal Zone QA - Qatar QO - Outlying Oceania RE - Réunion RO - Romania RS - Serbia RU - Russia RW - Rwanda SA - Saudi Arabia SB - Solomon Islands SC - Seychelles SD - Sudan SE - Sweden SG - Singapore SH - Saint Helena SI - Slovenia SJ - Svalbard and Jan Mayen SK - Slovakia SL - Sierra Leone SM - San Marino SN - Senegal SO - Somalia SR - Suriname ST - São Tomé and Príncipe SV - El Salvador SY - Syria SZ - Swaziland TA - Tristan da Cunha TC - Turks and Caicos Islands TD - Chad TF - French Southern Territories TG - Togo TH - Thailand TJ - Tajikistan TK - Tokelau TL - Timor-Leste TL - East Timor TM - Turkmenistan TN - Tunisia TO - Tonga TR - Turkey TT - Trinidad and Tobago TV - Tuvalu TW - Taiwan TZ - Tanzania UA - Ukraine UG - Uganda UM - U.S. Minor Outlying Islands US - United States UY - Uruguay UZ - Uzbekistan VA - Vatican City VC - Saint Vincent and the Grenadines VD - North Vietnam VE - Venezuela VG - British Virgin Islands VI - U.S. Virgin Islands VN - Vietnam VU - Vanuatu WF - Wallis and Futuna WK - Wake Island WS - Samoa YD - People's Democratic Republic of Yemen YE - Yemen YT - Mayotte ZA - South Africa ZM - Zambia ZW - Zimbabwe DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Date of Arrival
M-D-Y
Date of Departure
M-D-Y
Add Another Location +
AC - Ascension Island AD - Andorra AE - United Arab Emirates AF - Afghanistan AG - Antigua and Barbuda AI - Anguilla AL - Albania AM - Armenia AN - Netherlands Antilles AO - Angola AQ - Antarctica AR - Argentina AS - American Samoa AT - Austria AU - Australia AW - Aruba AX - Åland Islands AZ - Azerbaijan BA - Bosnia and Herzegovina BB - Barbados BD - Bangladesh BE - Belgium BF - Burkina Faso BG - Bulgaria BH - Bahrain BI - Burundi BJ - Benin BL - Saint Barthélemy BM - Bermuda BN - Brunei BO - Bolivia BQ - British Antarctic Territory BR - Brazil BS - Bahamas BT - Bhutan BV - Bouvet Island BW - Botswana BY - Belarus BZ - Belize CA - Canada CC - Cocos [Keeling] Islands CD - Congo - Kinshasa CD - Congo [DRC] CF - Central African Republic CG - Congo - Brazzaville CG - Congo [Republic] CH - Switzerland CI - Côte d'Ivoire CI - Ivory Coast CK - Cook Islands CL - Chile CM - Cameroon CN - China CO - Colombia CP - Clipperton Island CR - Costa Rica CS - Serbia and Montenegro CT - Canton and Enderbury Islands CU - Cuba CV - Cabo Verde CX - Christmas Island CY - Cyprus CZ - Czech Republic DE - Germany DG - Diego Garcia DJ - Djibouti DK - Denmark DM - Dominica DO - Dominican Republic DZ - Algeria EA - Ceuta and Melilla EC - Ecuador EE - Estonia EG - Egypt EH - Western Sahara ER - Eritrea ES - Spain ET - Ethiopia FI - Finland FJ - Fiji FK - Falkland Islands FK - Falkland Islands [Islas Malvinas] FM - Micronesia FO - Faroe Islands FQ - French Southern and Antarctic Territories FR - France FX - Metropolitan France GA - Gabon GB - United Kingdom GD - Grenada GE - Georgia GF - French Guiana GG - Guernsey GH - Ghana GI - Gibraltar GL - Greenland GM - Gambia GN - Guinea GP - Guadeloupe GQ - Equatorial Guinea GR - Greece GS - South Georgia and the South Sandwich Islands GT - Guatemala GU - Guam GW - Guinea-Bissau GY - Guyana HK - Hong Kong HM - Heard Island and McDonald Islands HN - Honduras HR - Croatia HT - Haiti HU - Hungary IC - Canary Islands ID - Indonesia IE - Ireland IL - Israel IM - Isle of Man IN - India IO - British Indian Ocean Territory IQ - Iraq IR - Iran IS - Iceland IT - Italy JE - Jersey JM - Jamaica JO - Jordan JP - Japan JT - Johnston Island KE - Kenya KG - Kyrgyzstan KH - Cambodia KI - Kiribati KM - Comoros KN - Saint Kitts and Nevis KP - North Korea KR - South Korea KW - Kuwait KY - Cayman Islands KZ - Kazakhstan LA - Laos LB - Lebanon LC - Saint Lucia LI - Liechtenstein LK - Sri Lanka LR - Liberia LS - Lesotho LT - Lithuania LU - Luxembourg LV - Latvia LY - Libya MA - Morocco MC - Monaco MD - Moldova ME - Montenegro MF - Saint Martin MG - Madagascar MH - Marshall Islands MI - Midway Islands MK - Macedonia MK - Macedonia [FYROM] ML - Mali MM - Myanmar [Burma] MN - Mongolia MO - Macau SAR China MO - Macau MP - Northern Mariana Islands MQ - Martinique MR - Mauritania MS - Montserrat MT - Malta MU - Mauritius MV - Maldives MW - Malawi MX - Mexico MY - Malaysia MZ - Mozambique NA - Namibia NC - New Caledonia NE - Niger NF - Norfolk Island NG - Nigeria NI - Nicaragua NL - Netherlands NO - Norway NP - Nepal NQ - Dronning Maud Land NR - Nauru NU - Niue NZ - New Zealand OM - Oman PA - Panama PC - Pacific Islands Trust Territory PE - Peru PF - French Polynesia PG - Papua New Guinea PH - Philippines PK - Pakistan PL - Poland PM - Saint Pierre and Miquelon PN - Pitcairn Islands PR - Puerto Rico PS - Palestinian Territories PT - Portugal PU - U.S. Miscellaneous Pacific Islands PW - Palau PY - Paraguay PZ - Panama Canal Zone QA - Qatar QO - Outlying Oceania RE - Réunion RO - Romania RS - Serbia RU - Russia RW - Rwanda SA - Saudi Arabia SB - Solomon Islands SC - Seychelles SD - Sudan SE - Sweden SG - Singapore SH - Saint Helena SI - Slovenia SJ - Svalbard and Jan Mayen SK - Slovakia SL - Sierra Leone SM - San Marino SN - Senegal SO - Somalia SR - Suriname ST - São Tomé and Príncipe SV - El Salvador SY - Syria SZ - Swaziland TA - Tristan da Cunha TC - Turks and Caicos Islands TD - Chad TF - French Southern Territories TG - Togo TH - Thailand TJ - Tajikistan TK - Tokelau TL - Timor-Leste TL - East Timor TM - Turkmenistan TN - Tunisia TO - Tonga TR - Turkey TT - Trinidad and Tobago TV - Tuvalu TW - Taiwan TZ - Tanzania UA - Ukraine UG - Uganda UM - U.S. Minor Outlying Islands US - United States UY - Uruguay UZ - Uzbekistan VA - Vatican City VC - Saint Vincent and the Grenadines VD - North Vietnam VE - Venezuela VG - British Virgin Islands VI - U.S. Virgin Islands VN - Vietnam VU - Vanuatu WF - Wallis and Futuna WK - Wake Island WS - Samoa YD - People's Democratic Republic of Yemen YE - Yemen YT - Mayotte ZA - South Africa ZM - Zambia ZW - Zimbabwe DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Date of Arrival
M-D-Y
Date of Departure
M-D-Y
Add Another Location +
AC - Ascension Island AD - Andorra AE - United Arab Emirates AF - Afghanistan AG - Antigua and Barbuda AI - Anguilla AL - Albania AM - Armenia AN - Netherlands Antilles AO - Angola AQ - Antarctica AR - Argentina AS - American Samoa AT - Austria AU - Australia AW - Aruba AX - Åland Islands AZ - Azerbaijan BA - Bosnia and Herzegovina BB - Barbados BD - Bangladesh BE - Belgium BF - Burkina Faso BG - Bulgaria BH - Bahrain BI - Burundi BJ - Benin BL - Saint Barthélemy BM - Bermuda BN - Brunei BO - Bolivia BQ - British Antarctic Territory BR - Brazil BS - Bahamas BT - Bhutan BV - Bouvet Island BW - Botswana BY - Belarus BZ - Belize CA - Canada CC - Cocos [Keeling] Islands CD - Congo - Kinshasa CD - Congo [DRC] CF - Central African Republic CG - Congo - Brazzaville CG - Congo [Republic] CH - Switzerland CI - Côte d'Ivoire CI - Ivory Coast CK - Cook Islands CL - Chile CM - Cameroon CN - China CO - Colombia CP - Clipperton Island CR - Costa Rica CS - Serbia and Montenegro CT - Canton and Enderbury Islands CU - Cuba CV - Cabo Verde CX - Christmas Island CY - Cyprus CZ - Czech Republic DE - Germany DG - Diego Garcia DJ - Djibouti DK - Denmark DM - Dominica DO - Dominican Republic DZ - Algeria EA - Ceuta and Melilla EC - Ecuador EE - Estonia EG - Egypt EH - Western Sahara ER - Eritrea ES - Spain ET - Ethiopia FI - Finland FJ - Fiji FK - Falkland Islands FK - Falkland Islands [Islas Malvinas] FM - Micronesia FO - Faroe Islands FQ - French Southern and Antarctic Territories FR - France FX - Metropolitan France GA - Gabon GB - United Kingdom GD - Grenada GE - Georgia GF - French Guiana GG - Guernsey GH - Ghana GI - Gibraltar GL - Greenland GM - Gambia GN - Guinea GP - Guadeloupe GQ - Equatorial Guinea GR - Greece GS - South Georgia and the South Sandwich Islands GT - Guatemala GU - Guam GW - Guinea-Bissau GY - Guyana HK - Hong Kong HM - Heard Island and McDonald Islands HN - Honduras HR - Croatia HT - Haiti HU - Hungary IC - Canary Islands ID - Indonesia IE - Ireland IL - Israel IM - Isle of Man IN - India IO - British Indian Ocean Territory IQ - Iraq IR - Iran IS - Iceland IT - Italy JE - Jersey JM - Jamaica JO - Jordan JP - Japan JT - Johnston Island KE - Kenya KG - Kyrgyzstan KH - Cambodia KI - Kiribati KM - Comoros KN - Saint Kitts and Nevis KP - North Korea KR - South Korea KW - Kuwait KY - Cayman Islands KZ - Kazakhstan LA - Laos LB - Lebanon LC - Saint Lucia LI - Liechtenstein LK - Sri Lanka LR - Liberia LS - Lesotho LT - Lithuania LU - Luxembourg LV - Latvia LY - Libya MA - Morocco MC - Monaco MD - Moldova ME - Montenegro MF - Saint Martin MG - Madagascar MH - Marshall Islands MI - Midway Islands MK - Macedonia MK - Macedonia [FYROM] ML - Mali MM - Myanmar [Burma] MN - Mongolia MO - Macau SAR China MO - Macau MP - Northern Mariana Islands MQ - Martinique MR - Mauritania MS - Montserrat MT - Malta MU - Mauritius MV - Maldives MW - Malawi MX - Mexico MY - Malaysia MZ - Mozambique NA - Namibia NC - New Caledonia NE - Niger NF - Norfolk Island NG - Nigeria NI - Nicaragua NL - Netherlands NO - Norway NP - Nepal NQ - Dronning Maud Land NR - Nauru NU - Niue NZ - New Zealand OM - Oman PA - Panama PC - Pacific Islands Trust Territory PE - Peru PF - French Polynesia PG - Papua New Guinea PH - Philippines PK - Pakistan PL - Poland PM - Saint Pierre and Miquelon PN - Pitcairn Islands PR - Puerto Rico PS - Palestinian Territories PT - Portugal PU - U.S. Miscellaneous Pacific Islands PW - Palau PY - Paraguay PZ - Panama Canal Zone QA - Qatar QO - Outlying Oceania RE - Réunion RO - Romania RS - Serbia RU - Russia RW - Rwanda SA - Saudi Arabia SB - Solomon Islands SC - Seychelles SD - Sudan SE - Sweden SG - Singapore SH - Saint Helena SI - Slovenia SJ - Svalbard and Jan Mayen SK - Slovakia SL - Sierra Leone SM - San Marino SN - Senegal SO - Somalia SR - Suriname ST - São Tomé and Príncipe SV - El Salvador SY - Syria SZ - Swaziland TA - Tristan da Cunha TC - Turks and Caicos Islands TD - Chad TF - French Southern Territories TG - Togo TH - Thailand TJ - Tajikistan TK - Tokelau TL - Timor-Leste TL - East Timor TM - Turkmenistan TN - Tunisia TO - Tonga TR - Turkey TT - Trinidad and Tobago TV - Tuvalu TW - Taiwan TZ - Tanzania UA - Ukraine UG - Uganda UM - U.S. Minor Outlying Islands US - United States UY - Uruguay UZ - Uzbekistan VA - Vatican City VC - Saint Vincent and the Grenadines VD - North Vietnam VE - Venezuela VG - British Virgin Islands VI - U.S. Virgin Islands VN - Vietnam VU - Vanuatu WF - Wallis and Futuna WK - Wake Island WS - Samoa YD - People's Democratic Republic of Yemen YE - Yemen YT - Mayotte ZA - South Africa ZM - Zambia ZW - Zimbabwe DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Date of Arrival
M-D-Y
Date of Departure
M-D-Y
Add Another Location +
In the past 14-days, did you travel domestically, outside of Hampton Roads (i.e. Chesapeake, Franklin, Hampton, Isle of Wight, Newport News, Norfolk, Poquoson, Portsmouth, South Hampton, and Virginia Beach)?* must provide value
Yes
No
Flight Layover(s)/Transfer Airport
Length of Layover
Date
M-D-Y
Airport
Length of Layover
Date
M-D-Y
Airport
Length of Layover
Date
M-D-Y
Any travel within your respective country?* must provide value
Yes
No
Domestic Travel Location of Travel (City) AL - Alabama AK - Alaska AS - America Samoa AZ - Arizona AR - Arkansas AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Arrival Date
M-D-Y
Departure Date
M-D-Y
Add Another Location +
Location of Travel (City) AL - Alabama AK - Alaska AS - America Samoa AZ - Arizona AR - Arkansas AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Arrival Date
M-D-Y
Departure Date
M-D-Y
Add Another Location +
Location of Travel (City) AL - Alabama AK - Alaska AS - America Samoa AZ - Arizona AR - Arkansas AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Arrival Date
M-D-Y
Departure Date
M-D-Y
Add Another Location +
In the past 14 days, have you been on a cruise?* must provide value
Yes
No
Cruise Information Date of Cruise
Today M-D-Y
Port Location
Add Another Location +
Date of Cruise
Today M-D-Y
Port Location
Add Another Location +
Date of Cruise
Today M-D-Y
Port Location
Add Another Location +
Have you had an exposure to a confirmed or suspected COVID 19 case during your travel: * must provide value
Yes
No
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Are you currently experiencing any signs or symptoms of COVID-19; including: * must provide value
Fever (100.4 degrees or higher)
Signs/symptoms of a lower respiratory illness (cough or shortness of breath)
Loss of sense of taste or smell
Sore Throat
Runny Nose
Abdominal Pain
Chills
Vomiting
Nausea
Diarrhea
Headache
Fatigue
General Malaise
Rash
Conjunctivitis
Muscle Aches
Joint Aches
Loss of Appetite
Nose Bleed
Other
N/A - I do NOT have any symptoms
Fever (100.4 degrees or higher)
Signs/symptoms of a lower respiratory illness (cough or shortness of breath)
Loss of sense of taste or smell
Sore Throat
Runny Nose
Abdominal Pain
Chills
Vomiting
Nausea
Diarrhea
Headache
Fatigue
General Malaise
Rash
Conjunctivitis
Muscle Aches
Joint Aches
Loss of Appetite
Nose Bleed
Other
N/A - I do NOT have any symptoms
M-D-Y
M-D-Y
Mild
Severe
Shortness of Breath: Date of Onset
M-D-Y
Mild
Severe
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Do you have any of the following risk factors? Over 65 years of age
History of chronic lung disease or moderate to severe asthma
History of serious heart conditions
History of chronic treatments/conditions that may leave you immunocompromised (e.g., cancer treatment, smoking, bone marrow and/or organ transplantation, immune deficiencies, poorly controlled HIV/AIDS, prolonged use of corticosteroids and/or other immune weakening medications)
BMI ≥ 40
History of diabetes
History of chronic kidney disease
History of liver disease
Hypertension
N/A - I do NOT have any risk factors
Over 65 years of age
History of chronic lung disease or moderate to severe asthma
History of serious heart conditions
History of chronic treatments/conditions that may leave you immunocompromised (e.g., cancer treatment, smoking, bone marrow and/or organ transplantation, immune deficiencies, poorly controlled HIV/AIDS, prolonged use of corticosteroids and/or other immune weakening medications)
BMI ≥ 40
History of diabetes
History of chronic kidney disease
History of liver disease
Hypertension
N/A - I do NOT have any risk factors
Please specify (check all that apply): Lung disease
Cancer
Hypertension
Heart Failure
Cardiovascular disease
Renal disease
Liver disease
Immunocompromised conditions
Sickle Cell Disease
Pregnancy
Lung disease
Cancer
Hypertension
Heart Failure
Cardiovascular disease
Renal disease
Liver disease
Immunocompromised conditions
Sickle Cell Disease
Pregnancy
Have you come in contact with someone who was confirmed or suspected to have COVID-19 * must provide value
Yes
No
Where did you encounter this individual(s) (check all that apply)? Work
Home
Visiting Medical Facility
Public Gathering
Airport
Outside
Other
Work
Home
Visiting Medical Facility
Public Gathering
Airport
Outside
Other
Residential Care Facility
Hospital
Medical Clinic (not working)
Other
Residential Care Facility
Hospital
Medical Clinic (not working)
Other
Throughout your travel, were you in close proximity to others who appeared to be experiencing signs or symptoms of COVID-19 (i.e. fever, cough, and/or shortness of breath)? * must provide value
Yes
No
Where did you encounter this individual(s) (check all that apply)? Clinical Setting
Airplane
Airport
Public
Inside
Outside
Other
Clinical Setting
Airplane
Airport
Public
Inside
Outside
Other
What were their signs/symptoms (if any) (check all that apply)? Cough
Shortness of Breath
Appeared "un-well"
Other
Cough
Shortness of Breath
Appeared "un-well"
Other
Throughout your travel, were you in close proximity to anyone who had been diagnosed with COVID19 or was later diagnosed with COVID19? Yes
No
Where did you encounter this individual(s) (check all that apply)? Clinical Setting
Airplane
Airport
Public
Inside
Outside
Other
Clinical Setting
Airplane
Airport
Public
Inside
Outside
Other
What were their signs/symptoms (if any) (check all that apply)? Cough
Shortness of Breath
Appeared "un-well"
Other
Cough
Shortness of Breath
Appeared "un-well"
Other
You have traveled internationally or domestically within the last 2 weeks. Travel increases your chances of getting and spreading COVID-19. There are no quarantine requirements for people arriving to the Commonwealth from other U.S. or international locations, as of October 7, 2020. Watch your health and take your temperature if you feel sick. If you choose to you can download the “Asymptomatic Exposed 14 day Symptom Self- Monitoring Form” on the EVMS MyPortal site at: https://myportal.evms.edu/covid-19resources/ to help you keep track of your symptoms. Should you develop any symptoms within 2 weeks of your return date please complete and submit the EVMS/EVMS Medical Group Exposure Survey
If you have any questions please contact Human Resources at 446-6043 or for students please contact Student Health at 446-5700.
You have traveled internationally or domestically within the last 2 weeks and/or have symptoms that might be consistent with COVID 19 and further evaluation by Student Health for students or Occupational Health for employees is needed. Please complete and submit the EVMS/EVMS Medical Group Exposure Survey.
Please do not report to work and notify your supervisor. If you are currently at work, leave work immediately and notify your supervisor. Occupational Health or Student Health (whichever is applicable) will reach out to you on the following business day. If you do not receive a call before noon on the following business day, please contact Student Health at 446-5700 if you are a student or all others please contact Occupational Health at 446-5870. For urgent questions only AND if it outside of normal Occupational Health business hours, the exposure pager may be called at (757)669-1157. Please note that testing for COVID 19 in the drive through is done by appointment only and conducted Monday through Friday.