Fillable Travel Reporting Form Due to the health risks (Northern Essex Community College)

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Travel Reporting Form Due to the health risks (Northern Essex Community College)

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_______________________________________________)
______________________________________________ ___)
:
Travel Reporting Form
Due to the health risks associated with the coronavirus, the College is establishing a reporting
system for students, faculty and staff traveling internationally, especially to countries where travel
advisories have been issued by the CDC. Reporting is strongly encouraged so that the College can
take appropriate preventative measures, offer available resources, and immediately assist any
member of our community who may become ill or has been in close proximity with someone who
has become ill. Also, the information reported will assist the College in implementing any
precautions or protocols recommended by public health agencies.
Name:
Status: Student (Student Identification #: )
Faculty (Department:
Staff (Department:
Email Address:________________________________________ Phone #:________________
Location of Travel: China
Iran
Italy
South Korea
Japan
Hong Kong
Other: _______________________________________________
Dates of Travel Depart:_______________________ Return:_______________________
Method of Travel: Air
Sea
Land
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Travel Reporting Form Due to the health risks (Northern Essex Community College)

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Completed 17 September 2020

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