Employee Travel Questionnaire

EMPLOYEE TRAVEL QUESTIONNAIRE

Employee Name (Required):

Email Address (Required):

Phone Number (Required):

Travel Date (Returning):

Planned Return to Work Date:

Travel Destination(s)*

Please List Destinations and also include Connections and Layovers

Will any part of your travel be on a cruise ship?:
YesNo

Traveling with anyone?:
YesNo

What is your reason for travel?:

COVID VACCINE*

Have you received the COVID vaccine? If “yes”, please provide dates.

YesNo

VACCINE #1 DATE:

VACCINE #2 DATE:

I acknowledge upon returning back to work that I may be asked to quarantine or be tested upon returning to the field.

Full Name (Digital Signature Required):
Date (Required):