COVID-19 Disclosure and International Travel Form

Please fill out this form if you have been exposed or diagnosed with COVID-19, if you have upcoming international travel plans, or have traveled internationally.

In accordance with Goodwin University’s COVID-19 International Travel and Exposure Disclosure Procedure all members of the Goodwin community, including students, faculty, staff and campus-based third-party vendors, must complete this form as soon as practicably possible. For more information on this policy, and what’s being done to keep the Goodwin community safe, visit the webpage.

Your information will be protected, and will only be shared on an as-needed basis.

Your Information

First Name

Last Name

Affiliation

Role

Student ID (if applicable)

Phone

Goodwin Email Address

I am reporting possible exposure to COVID-19

I am disclosing that I have travelled internationally or have upcoming international travel

Explain how you were exposed

Travel #1

Date of travel (start)

Date of travel (end)

Locations during this trip (includes areas visited, or stopped in during a layover)

Type of Travel

Business Academic Leisure

If traveling for business or academic, describe the trip’s purpose:

Travel #2

Date of travel (start)

Date of travel (end)

Locations during this trip (includes areas visited, or stopped in during a layover)

Type of Travel

Business Academic Leisure

If traveling for business or academic, describe the trip’s purpose:

Travel #3

Date of travel (start)

Date of travel (end)

Locations during this trip (includes areas visited, or stopped in during a layover)

Type of Travel

Business Academic Leisure

If traveling for business or academic, describe the trip’s purpose:

If you are human leave this field blank