Fillable GOVERNMENT OF THE VIRGIN ISLANDS DEPARTMENT OF HEALTH

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GOVERNMENT OF THE VIRGIN ISLANDS DEPARTMENT OF HEALTH

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GOVERNMENT OF
THE VIRGIN ISLANDS
DEPARTMENT OF HEALTH
ST. CROIX OFFICE ST. THOMAS OFFICE
CHARLES HARWOOD COMPLEX 1303 HOSPITAL GROUND, SUITE 10 3500
ESTATE RICHMOND CHARLOTTE AMALIE
CHRISTINASTED, ST. CROIX, VI. 00820-4370 ST. THOMAS, VI 00802-6722
TEL: (340) 718-1311 TEL: (340) 774-0117
Virgin Islands Department of Health
COVID-19 Traveler Screening Tool
The information is being collected as a part of the public health response to the outbreak of the coronavirus in many countries in the
World and the United States. The information will be used by the Epidemiology Division within the Department of Health as part of the
surveillance activities aimed at reducing the transmission of the COVID-19 virus in the territory.
Section 1: Passenger Information
Name (Last, First, MI)
Sex:
M F
Date of Birth(dd/mm/yyyy)
Traveling with anyone?
Y N
Relationship:
Name(s)
What is the purpose of your trip?
Business___ Vacation____ Returning home___ Other (specify)_____
Section 2: Contact Information
Local Address (if staying in the territory):
Work Phone:
Cell Phone:
Email Address(work)/ Email address(personal):
Section 3: Public Health Information
Today or in the past 14 days, have you had any of the following symptom?
1.
Fever (100.4 F) or higher
2.
Fatigue
3.
Body aches
4.
Persistent Cough
5.
Difficulty Breathing
6.
Loss of taste and smell
7.
Any other symptoms (Please indicate):
8.
Lived in a household or had contact with a person sick with COVID-19?
9.
Have been in contact with a person or persons who tested positive for COVID-19?
Section 4: Recent Travel Information
List the state or country of embarkation prior to arrival into the Territory.
State/Country: ___________________________________________________________
Airport: _________________________________________________________________
__________________________________
I attest that all the information provided here in are true and accurate. I have been notified that I must
adhere to all local COVID-19 mandates and regulations.
Signature: _______________________________ Date: __________________
Section 5: COVID-19 Traveller Test Results
(
Authorized Persons Only)
Name of Traveller:
Date of Birth:
Type of Test Presented:
PCR Antibody No Test Presented
Results:
Positive Negative
Date of Test
(dd/mm/yyyy)
Name of Traveller:
Date of Birth:
Type of Test:
PCR Antibody No Test Presented
Results:
Positive Negative
Date of Test
(dd/mm/yyyy)
Name of Traveller:
Date of Birth:
Type of Test Presented:
PCR Antibody No Test Presented
Results:
Positive Negative
Date of Test
(dd/mm/yyyy)
Name of Traveller:
Date of Birth
Type of Test:
PCR Antibody No Test Presented
Results:
Positive Negative
Date of Test
(dd/mm/yyyy)
Name of Traveller:
Date of Birth:
Type of Test Presented:
PCR Antibody No Test Presented
Results:
Positive Negative
Date of Test
(dd/mm/yyyy)
Name of Traveller:
Date of Birth
Type of Test:
PCR Antibody No Test Presented
Results:
Positive Negative
Date of Test
(dd/mm/yyyy)
Name of Traveller:
Date of Birth:
Type of Test Presented:
PCR Antibody No Test Presented
Results:
Positive Negative
Date of Test
(dd/mm/yyyy)
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GOVERNMENT OF THE VIRGIN ISLANDS DEPARTMENT OF HEALTH

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Completed 8 October 2020

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