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VACCINATION STATUS
1. Have you had all of the required dose(s) of your vaccine Yes No
(2 doses for Moderna and Pfizer, 1 dose for Janssen/Johnson & Johnson)
2. Date of final dose: _____/_____/_____
(Month/Day/Year)
RECOVERED FROM CONFIRMED COVID-19 ILLNESS
1. Have you previously been diagnosed as having COVID-19? Yes No
2. If you had symptoms, date symptoms began: _____/_____/_____ (Month/Day/Year)
3. If you did not have symptoms, date of first positive diagnostic test: _____/_____/_____ (Month/Day/Year)
QUARNATINE REQUIREMENTS AND RECOMMENDATIONS
All New Yorkers, as well as those visiting from out of state, are required to comply with all COVID-19 safety
measures including wearing face coverings, social distancing and avoiding group gatherings and vulnerable
populations in the best interest of public health.
• Domestic Travelers: Asymptomatic domestic travelers arriving in New York State from other U.S. states and
territories are not required to test or quarantine. Domestic travelers do not need to quarantine if they are
fully vaccinated or have recovered from laboratory confirmed COVID-19 within the previous 3
months. However, while not required, quarantine is still recommended for all other asymptomatic domestic
travelers for either 7 days with a test 3-5 days after travel or 10 days without a test.
• Symptomatic domestic travelers must self-isolate immediately and contact their health care provider or
local health authority to determine if they should seek testing.
• International Travelers: Per CDC, all international travelers must quarantine for either 7 days with a test 3-5
days after travel, or quarantine for the full 10 days without a test. This requirement applies to all international
travelers whether they were tested before boarding, are recovered from a previous COVID infection, or are
fully vaccinated.
• Travelers from border states (NJ, CT, PA, MA, VT) are not required to quarantine. Non-essential travel is
discouraged.
• All travelers, both domestic and international, must continue to monitor symptoms through day 14. If any
symptoms develop, travelers should immediately self-isolate and contact their health care provider or local
health authority to report this change and determine if they should seek testing.
• NYS does not grant exemptions from the travel advisory for international travel. For more information,
international travelers should consult the CDC website.
• CDC provides limited exemptions for flight crews.
ADDITIONAL INFORMATION
• For additional information regarding the NYS Travel Advisory visit: https://ny.gov/traveladvisory
• Upon entering New York State, if you are a traveler and do not have a suitable dwelling for your quarantine
period, you must find appropriate accommodations at your own cost. If you are a NYS resident returning from
travel and do not have appropriate accommodations for quarantine, please call your local health department:
www.health.ny.gov/contact/contact_information/
ATTESTATION
I hereby attest, under penalty of law, that all information that I have provided is true and accurate to the best of my
knowledge.
__________________________________________________________ ______________________
Signature Date