Business & Personal Travel Disclosure

ASCC employees must report any potential exposure as a result of out-of-state travel that has occurred in the past 14 days. This form is to be completed within 24 hours post travel. Travel that must be reported includes:

The employee has traveled or plans to travel out of state for business or personal purposes.

The employee has been in close contact with a spouse or significant other who has traveled out of state for any reason.

The employee has been in close contact with an acquaintance such as a friend or family member who has traveled out of state.

The employee has been in close contact with out-of-state visitors.

Employees who have encountered any of these scenarios will be required to complete a 14 day self-quarantine prior to returning to the office or in-person services.

First Name*
Last Name*
Employee Email*
Who will be traveling?*
Travel City, State, & Zip*
First Day of Travel*
Date Format: MM slash DD slash YYYY
Last Day of Travel*
Date Format: MM slash DD slash YYYY
Who has traveled?
Acknowledgement*
I understand that for my health and safety and for the health and safety of my colleagues, participants and community members, I must complete a 14 day self-quarantine upon my return from any out-of-state travel or exposure to someone who may have traveled, regardless of the reason for the travel. I understand that I may work from home during this time if work is available; however, should work not be available, I may use PTO or my time will be unpaid. I also understand that should I not disclose my travel or choose to not comply with the 14 day self-quarantine, I may face disciplinary action.