Coronavirus (COVID-19) Travel Disclosure Form

1. Have you recently travelled internationally, or to a restricted area of the incountry

in the past 14 days?

Yes
No

If Yes, do not travel and self-isolate immediately, even if asymptomatic.

a. Are you displaying, or have you displayed the following symptoms in the
last 7 days:

I. Fever
II. Cough
III. Difficulty breathing

Yes
No

If Yes, do not travel and self-isolate immediately.

2. Have you been in contact with any confirmed or suspected case of Coronavirus in
the last 14 days?

Yes
No

If Yes, do not travel and monitor for symptoms.

Date: _______________________________________________

Name: ______________________________________________

Company: ___________________________________________