ESMW Travel Questionnaire
Please answer the questions below upon your return from any travel outside of your local area. Current CDC guidance is specifically for those who are fully vaccinated and non-vaccinated people.
The questionnaire should be completed at least 24 hours before your next scheduled shift.
Please be prepared to show prove of vaccination and/or testing results.
 
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Employee Name (First, Last) *
Employee Phone Number *
Department *
Please enter name of program you work in. (i.e. Human Resources, Administration, Autism, Community Living, Employment, etc.)
Supervisor Name (First, Last) *
Travel Type: *
Travel Destination: *
What City and State did you visit? (If multiple please list all.)
Travel Departure Date: *
What date did you leave?
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Travel Return Date: *
What date did you Return?
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Return to Work Date *
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Vaccination Status *
1. Did you travel with others who are not in your immediate household? *
2. Did you practice social distancing when around others who weren't a part of your group? *
3. Did you participate in any large gatherings? (i.e. funeral, beach, concert, party, wedding, theme park, etc.) This includes holiday gatherings with 10 or more people; and/ or with people outside of your immediate household. *
4. Did you or anyone in your travel group become ill/ symptomatic during you trip? *
4a.  If "Yes", Identify symptoms person was experiencing:
5. Anyone with pending or confirmed COVID-19 results? *
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