Weekly Check-in I Covid-19

Are you currently in the United States?*

Yes
No

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STILL IN THE USA

Name*

First Last

AAG ID

Phone number*

Email*

Country of Citizenship*

Please provide your current address in the United States:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Where are you staying?*

In housing provided by my Host Employer
In housing I secured on my own
Staying with Family members or friends
Other

Please explain:*

Are you paying for your housing?*

Yes
No

How much do you pay?

When is your next rent payment due?

Are you paying for your food?*

Yes
No

How much do you pay per week?

Are you currently working/training?*

Yes
No

Is your Employer listed on your DS2019?

Yes
No

Please report your job to alliance abroad at https://participants.allianceabroad.com/second-job/

Are you safe, well and healthy?*

Yes
No

Please explain*

If you are not safe, well and healthy, please contact AAG immediately on our 24-Hour Support Line 1-866-622-7623. You may also contact your Outreach Coordinator or email us at [email protected]. We want to hear from you and help you right away.

Would you like Alliance Abroad to call you after reviewing information provided in this survey?*

Yes
No

Please confirm the phone number where we can reach you

Do you have a departure date from the United States?

Yes
No
I have no plans to depart the United States

Please explain*

Departure date:*

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NOT IN USA

When did you depart the United States?

Thank you for letting us know that you are in your home country.

Name

First Last

Email

COVID-19

CHECK-IN

For emergencies, please call Alliance Abroad at 1-866-622-7623

STILL IN THE USA

NOT IN USA