COVID-19 Travel Screening Form All individuals over the age of 18 and unaccompanied minors entering Rhode Island, including Rhode Island residents returning from out-of-state travel, who are coming from 1) a high-risk COVID state for non-work related purposes or 2) from outside the United States, must complete this form upon or prior to entry to the state. All information provided will only be used by RIDOH to assist in the State’s response to the COVID-19 Pandemic. We appreciate your time. This information is needed as part of Governor Raimondo's Executive Order on phased re-opening which requires persons coming to Rhode Island to immediately self-quarantine for 14 days unless you: Are coming from a low-risk state (i.e., a state that is not on this list of states with a COVID-19 positivity rate of higher than 5%); Are coming from a high-risk state and can provide proof of a negative test for COVID-19 that was taken within the 72 hours prior to your arrival in Rhode Island; or Meet an exemption criteria (public health, public safety, or healthcare workers; anyone traveling for medical treatment or to attend funeral or memorial services; anyone traveling to obtain necessities such as groceries, gas or medication; anyone traveling to drop off or pick up children from day care or to anyone who must work on their boats). Any person arriving from a location outside the 50 states or the District of Columbia must immediately self-quarantine for 14 days upon arrival in Rhode Island. Any person who has travelled outside the 50 states or the District of Columbia in the last 14 days must self-quarantine for the remainder of the 14-day period upon arrival in Rhode Island. Quarantining for 14 days is always preferred over relying on a negative test result as quarantining is the best way to limit the possibility of spreading COVID-19. Failure to complete this form or failure to comply with the quarantine if applicable may result in a $500 fine per violation. By completing this form, you consent to receive text messages from the state of Rhode Island. If you have indicated that you will be quarantined, or plan to get a COVID-19 test, you will receive text message reminders starting on your arrival date and for the following 14 days or until your departure date, whichever comes first. Message and data rates may apply. For help, reply HELP. To opt-out, reply STOP. Self-quarantine instructions are posted on RIDOH’s website at health.ri.gov/diseases/ncov2019/#quarantine. Please give all the information needed below. 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
