Report Employee Travel

Form ONLY needed for international and cruise travel. The results of this form will be sent to Employee Health.

Name of Employee:
Phone:
Work Email:
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:
Did you receive a COVID-19 test in order to return the United States?	Yes No If yes, submit test results to Employee Health upon return to work.
When are you schedued to return to work?

Name of Employee:
Phone:
Work Email:
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:
Did you receive a COVID-19 test in order to return the United States?	Yes No If yes, submit test results to Employee Health upon return to work.
When are you schedued to return to work?