COVID-19 Testing Consent Form Traveler Information First Name Last Name Middle Initial Are You a Rhode Island Resident? Yes No Date of Birth Cell Phone Email Address Home Street Address Home City Home State Home Zip Companion Traveler Information Traveler 2 Relationship Cell Phone Traveler 3 Relationship Cell Phone Traveler 4 Relationship Cell Phone Traveler 5 Relationship Cell Phone Travel Itinerary Country before arrival in the US? (Note: Select “None” if you are not arriving from another country) None United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao, People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe State(s) visited before arrival in RI? (Note: Select “None” if you are not arriving from another state) None AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaDistrict of ColumbiaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin IslandsArmed Forces AfricaArmed Forces AmericasArmed Forces CanadaArmed Forces EuropeArmed Forces Middle EastArmed Forces Pacific Date of arrival to Rhode Island Planned date of departure How did you arrive into Rhode Island? Car Airplane Train Bus Other Rhode Island Destination Details Address Contact Name Phone Number Illness Monitoring Are you feeling sick? Yes No Are any of those traveling with you feeling sick? Yes No Have you or anyone traveling with you experienced...? Chills --None--Yes No Unknown Congestion --None--Yes No Unknown Cough --None--Yes No Unkown Diarrhea --None--Yes No Unknown Fatigue --None--Yes No Unknown Fever --None--Yes No Unknown Headache --None--Yes No Unknown Loss of Smell --None--Yes No Unknown Loss of Taste --None--Yes No Unknown Muscle Aches --None--Yes No Unknown Nausea --None--Yes No Unknown Shortness of Breath/Difficulty Breathing --None--Yes No Unknown Sore Throat --None--Yes No Unknown Vomiting --None--Yes No Unknown COVID-19 Test and Quarantine Status I certify that at least one of the following is true: (Choose 1) I am quarantining for 14 days; I plan to get a COVID-19 test in Rhode Island and will quarantine for a period of 14 days or until I receive a negative test result, whichever comes first (NOT APPLICABLE to travelers from outside the 50 states or the District of Columbia who must quarantine for 14 days). For more information on COVID testing in Rhode Island, visit health.ri.gov/covid/testing/; I was tested for COVID-19 within 72 hours of my arrival in Rhode Island or after my arrival in Rhode Island (NOT APPLICABLE to travelers from outside the 50 states or the District of Columbia who must quarantine for 14 days) and (choose 1 from the below options): My test result was negative; or I will remain in quarantine for a period of 14 days or until I receive a negative test result; or My test result was positive, for which I have remained and will continue to remain in isolation in accordance with Governor Raimondo’s Executive Orders or; I meet a defined exemption criteria (public health, public safety or healthcare workers; anyone traveling for medical treatment, to attend funeral or memorial services, to obtain necessities such as groceries, gas or medication, to drop off or pick up children from day care or to anyone who must work on their boats). Attestation By submitting this form, I hereby attest, under penalty of law, that all the information I have provided is true and accurate to the best of my knowledge. Cancel Submit
