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Travel Questionnaire Instructions

Travel Questionnaire 

When you download the file on a computer, you will be able to fill it out, save it and email it back to us. 

Filling Out the Questionnaire

Give us your preferred contact information in case we have questions for you. Check the type of insurance you have.  Check your preference of how you would like to receive your Travel Recommendations and Materials and indicate your preferred  day(s) and time slot(s) for your immunization appointment. 

Complete parts 1-7 and read relevant topics on the CDC Traveler’s Health web sites.

1. List ALL  the countries you will or might visit  in order by the date you will enter each country.  Include airport layovers in countries with risk of yellow fever transmission.  Yellow Fever occurs in parts of Panama, South America and Africa.  Go to Countries with risk of yellow fever virus transmission and scroll to Table 3-21 for a list.  Proof of Yellow Fever vaccination may be required for entry if coming from these countries and may apply to airport layovers ≥ 12 hours.  If after submitting your questionnaire you find out you will have a layover in a country with risk of Yellow Fever transmission, call the travel clinic (919 966-9176) to let us know!  For university based travel, read your program’s  requirements carefully. Yellow Fever vaccination may be “required” by your program.  In the event of an emergency evacuation  into a country with risk of Yellow Fever, your destination country  may require proof of Yellow Fever vaccination for re-entry. 

NOTE:  If you are traveling under a passport issued by a  country with yellow fever transmission risk, YOU should check with your destination regarding entry requirements.

List the cities or regions you will visit and length of stay.  Give us your best estimate of your plans if your itinerary is uncertain.  This is very  important for areas with malaria.

List date you will return to the USA.

The reason for travel helps in the assessment of your travel-related risks.

If travel is University-related (study abroad, exchange programs, internships, service/research projects), you are REQUIRED to go to http://globaltravel.unc.edu and log into the Global Travel Registry.  Personal recreational travel may be registered. The purpose of the registry is to facilitate communication with members of the Carolina community who may find themselves in an international crisis situation and to provide assistance. The information you provide will only be used for communication purposes in such situations.

2.  REQUIRED:  Give dates of immunizations that you have received. Please fill in the form, although attachments are allowed.  We have access to records previously submitted to CHS.   If you need  access to your past immunization records, contact the CHS Health Information desk at 919 966-2283. Dates of immunizations received at CHS can be accessed through the Healthy Heels Portal.   

3.  Check all potential activities that apply and check the type of accommodations you anticipate having while abroad.

4.  Check Y or N for each item in the Medical Conditions section.

5.  List any medical problems you have or have had not listed in previous section or Check NoneSee your physician for any ongoing medical conditions. Travelers need to have a plan to handle “flares” in conditions such as asthma, ulcerative colitis, etc.

6.  List ALL of the medications you take including Over-The-Counter items. Check  None if you take no medications.

7.  List allergies and describe reactions to medications, vaccines or food.  Include severe insect allergies. Check  None if no allergies.

Review http://www.cdc.gov/travel "Travelers’ Health Vaccines. Medicines. Advice.” for your destinations.  Read the recommendations for  each region you will visit and relevant topics at CDC Traveler Information CenterSign & date your form.

Submit your travel questionnaire by email or by dropping off a hard copy at Student Stores Pharmacy or the 2nd floor of Campus Health. Thanks for allowing us to be part of your journey!

 Travel Questionnaire 

Last Updated January 2018