GOVERNMENT OF THE VIRGIN ISLANDS DEPARTMENT OF HEALTH
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? …
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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 Address(physical): 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? Yes No 1. Fever (100.4 F) or higher Yes No 2. Fatigue Yes No 3. Body aches Yes No 4. Persistent Cough Yes No 5. Difficulty Breathing Yes No Don’t Know 6. Lived in a household or had contact with a person sick with COVID-19? Yes No Don’t Know 7. Have been in contact with a person or persons who tested positive for COVID19(Coronavirus) Section 4: Recent Travel Information Countries Visited: List all states or countries visited during your travel before arrival to the Territory (include all transit stops and airports) State/Country:_______________________________ Airport:____________________________________ State/Country:______________________________ Airport:___________________________________ State/Country:_______________________________ Airport:____________________________________ State/Country:______________________________ Airport:__________________________________ I attest that all the information provided here in are true and accurate. I have been notified that I must monitor my symptoms for a period of 3 days and to self-quarantine for 14 days. Signature: _______________________________Date: __________________ no