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:
If you travelled 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:
When are you schedued to return to work?