Report Employee Travel

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

Group of CMH Employees
Name of Employee:
Phone:
Work Email:

Where did you travel:

Country:
  City:
  State:
Date(s) of Travel:
If you traveled by plane, what airports did you travel through?
Did you have any exposure to sick individuals during your trip?


Are you experiencing any symptoms:   No Symptoms Fever  Cough  Shortness of Breath
Comments:
Do you work in a Long Term Care facility?


When are you schedued to return to work?