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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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* Indicates required question
Employee Name (First, Last)
*
Your answer
Employee Phone Number
*
Your answer
Department
*
Please enter name of program you work in. (i.e. Human Resources, Administration, Autism, Community Living, Employment, etc.)
Your answer
Supervisor Name (First, Last)
*
Your answer
Travel Type:
*
Domestic
International
Travel Destination:
*
What City and State did you visit? (If multiple please list all.)
Your answer
Travel Departure Date:
*
What date did you leave?
MM
/
DD
/
YYYY
Travel Return Date:
*
What date did you Return?
MM
/
DD
/
YYYY
Return to Work Date
*
MM
/
DD
/
YYYY
Vaccination Status
*
Fully Vaccinated
Partially Vaccinated
No Vaccination
1. Did you travel with others who are not in your immediate household?
*
Choose
Yes
No
2. Did you practice social distancing when around others who weren't a part of your group?
*
Choose
Yes
No
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.
*
Choose
Yes
No
4. Did you or anyone in your travel group become ill/ symptomatic during you trip?
*
Yes
No
4a. If "Yes", Identify symptoms person was experiencing:
Fever (greater than 100.4)
Shortness of Breath/ Difficulty Breathing
New onset Dry Cough
Body Ache/Chills
Loss of Taste Smell
Headache
Vomiting
Diarrhea
Nausea
N/A - Not Applicable
Other:
5. Anyone with pending or confirmed COVID-19 results?
*
Yes
No
Other:
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