First Name * Last Name * Student ID Number * Campus Residence * Email * Cell Phone Number * Are you experiencing any COVID-19 related symptoms? * Yes No This is a: * Day Trip Overnight Trip I am going: * to a grocery store to a retail store to get a COVID test home to visit family to a restaurant to an off campus job Other... I am going: Other... Are you traveling out of state? * Yes No Are you traveling to a COVID-19 hot spot? * Yes No How will you be traveling? * I am driving I am flying I am riding with other Millikin students taking an Uber/Lyft walking Other... How will you be traveling? Other... Date Leaving Campus * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202120222023 Time Leaving Campus * Hour Hour123456789101112 : Minute Minute000510152025303540455055 am pm Date Returning to Campus * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202120222023 Estimated Time Returning to Campus * Hour Hour123456789101112 : Minute Minute000510152025303540455055 am pm Please describe your job and work schedule. * By submitting this form I agree to wear face covering at all times when not eating/alone, practice social distancing and follow all community posted guidelines. I also understand that this form will be used for contact tracing for COVID-19. Leave this field blank
