Travel Health Risk Assessment Form for Employees
Employee Name
Employee ID
Department
Contact Information
Travel Details
Destination(s)
Departure Date
Return Date
Purpose of Travel
Medical Information
Do you have any existing medical conditions?
Are you currently taking any medication?
Do you have any allergies?
Required/Recommended Vaccinations Received for Travel
Additional Health & Safety Considerations
Have you experienced any illness in the past 30 days?
Any concerns regarding your health and the intended travel?
Emergency Contact Name
Emergency Contact Phone