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State Traveler -Form Fill

Section One

Name

First Name

Name

Last Name

Email

Phone Number

Is Phone Number a Mobile Number?

Yes

Alternate Number

Is Alternate Number a Mobile Number?

Yes

Date of Birth

Date

Age

Q10

Primary State of Residence

Q11

Date of Arrival

Date

Q12

In The Last 10 Days Have You Been In a State (not bordering NYS), US Territory, OR Another Country?

Yes

Q13

List state/country

Q14

Last date in state/country

Date

Q15

Other state/country

Q16

Destination Address in New York State

Street Address

Q17

Destination Address in New York State

Street Address Line 2

Q18

Destination Address in New York State

City

Q19

Destination Address in New York State

State / Province

Q20

Destination Address in New York State

Postal / Zip Code

Q21

County

Q22

Hotel Name

Q23

For New York residents, is final destination listed your primary residence?

Yes

Q24

For non-New York State residents, duration of visit in NYS

Q25

How did you travel into New York? (select all that apply)

Q26

TODAY OR IN THE PAST 24 HOURS, HAVE YOU HAD ANY OF THE FOLLOWING SYMPTOMS?

Q27

You will be called by a representative of the New York State Contact Tracing Program. Do you consent to receive messages via text? (If you do not consent to text, you will be called to clarify any information needed

Yes

Q28

What is your primary language?

Q29

Have you had all of the required dose(s) of your vaccine?

Q30

Date of final dose

Date

Q31

Have you previously been diagnosed as having COVID-19?

Yes

Q32

If you had symptoms, date symptoms began:

Date

Q33

If you did not have symptoms, date of first positive diagnostic test

Date

Q34

Signature

Q35