Report Employee Travel

Please fill out this form to report recent travel information. The results of this form will be sent to Employee Health.

Name of Employee:
Phone:
Where did you travel:	Country:
	City:
	State:
Date(s) of Travel:
Mode(s) of Transportation:
Did you have any exposure to sick individuals during your trip?	Yes No
Are you experiencing any symptoms:	No Symptoms Fever Cough Shortness of Breath
Comments:

Name of Employee:
Phone:
Where did you travel:	Country:
	City:
	State:
Date(s) of Travel:
Mode(s) of Transportation:
Did you have any exposure to sick individuals during your trip?	Yes No
Are you experiencing any symptoms:	No Symptoms Fever Cough Shortness of Breath
Comments: