ENMU-Roswell Travel Questionnaire

This information is being requested to reduce the spread of Coronavirus. The information will be reviewed to determine if you need to self-isolate accordance with the NM Dept. of Health Travel Recommendations. Students and employees, including student employees, must fill out this form if they, or a member of their household, have traveled out of the state of New Mexico in the last 14 days or been in contact with an individual who has tested positive for COVID-19. In the last 14 days If you have not traveled out of state or been in contact with an individual identified as having tested-positive for COVID-19 you are not required to complete this form.
Name*
First Last
ENMU-Roswell Classification*
- Student Employee
- Faculty
- Staff
Name of Supervisor*
First Last
Email*
Enter Email Confirm Email
I traveled outside of the state of New Mexico in the last 14 days.*
- Yes
- No
I have been in contact with an individual who has tested positive for COVID-19 in the last 14 days.*
- Yes
- No
Date of Contact?
Date Format: MM slash DD slash YYYY
Please provide detailed information about where you and/or your household member traveled, including but not limited to stops made, mode of transportation etc.:*
Departure Date from Roswell/Chaves County*
Date Format: MM slash DD slash YYYY
Return Date to Roswell/Chaves County*
Date Format: MM slash DD slash YYYY
Your contact phone number?*