Report Employee Travel

Form ONLY needed for international and cruise travel. 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:
Did you have any exposure to sick individuals during your trip?


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?


If yes, submit test results to Employee Health upon return to work.

When are you schedued to return to work?