COVID-19 Self-Isolation Request Form Notice: This form requires Javascript. If you are a human and are seeing this field, please leave it blank. Requester * Dr. Millie Wenger Dr. Kimberly Tilley Dr. Vicky Dunn Alicia Burnett Thu Nguyen-Knowles Student Or Staff Member * StudentStaff Member Was this a workplace exposure? YesNo Guest Name * USC ID # * Guest Email * Phone * Location * USC Hotel Check-In Date * Check-Out Date * Will The Guest Park A Vehicle At The Hotel? NoYes Make, Model, And Color Of Vehicle Evacuation Location * Within the US (including Local) USC Study Abroad Program Out of the Country (Personal Travel) Does The Guest Have Any Dietary Restrictions? NoneVegetarianVeganOther List Other Dietary Restrictions * Required Fields
