Health and Travel History Declaration

Ask staff to declare recent trips abroad, quarantine orders, medical certificates and possible exposure before they return to the workplace. Answers are timestamped and signed, giving occupational health a clear screening trail. Useful for employers operating under public health reporting rules.

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Staff name

Nombre

Apellido

Last 4 digits of your ID number

Department

Have you travelled abroad in the past 7 days, including neighbouring countries?*

Yes No

If yes, list the countries visited, how long and when

Have you been given a quarantine, isolation or stay-home order in the past 7 days?*

Yes No

If yes, provide the details

Have you been issued a medical certificate for respiratory symptoms in the past 7 days? If yes, give the dates below*

Yes No

Medical certificate valid from

Medical certificate valid to

Have you had close contact with a suspected or confirmed COVID-19 case?*

Yes No Not sure

If you or someone in your household took a swab test, give the date and result if known

Have you visited any location flagged by health authorities as an exposure site?*

Yes No Not sure

If yes, describe the visit

Signature

Sign here

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