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:
Work Email:
Where did you travel:	Country:
	City:
	County:
	State:
Date(s) of Travel:
Mode(s) of Transportation:
If you traveled by plane, what airports did you travel through?
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:
Do you work in a Long Term Care facility?	Yes No
When are you schedued to return to work?

Name of Employee:
Phone:
Work Email:
Where did you travel:	Country:
	City:
	County:
	State:
Date(s) of Travel:
Mode(s) of Transportation:
If you traveled by plane, what airports did you travel through?
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:
Do you work in a Long Term Care facility?	Yes No
When are you schedued to return to work?

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