Travel History Form - Usc Engemann Student Health Center
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1
2Travel History Form
A pdf online version of this form may be completed at: (click forms) and e-mailed as an attachment to: uphctrvl@usc.edu
Name:
:
10-Digit USC ID No.
Address:
Male
Today's Date:
/
/
Date of Birth:
/
/
Female
Home Telephone No.: (
)
Work Telephone No.: (
)
E-Mail Address:
Do you have a current passport or visa?
Yes
No
Dont' Know
Travel Specifics
Purpose of Trip:
School Related Study/Work
What school?
Pleasure
Business
Other:
What will you be doing on this trip?
Does your program require the completion of a medical form by a practitioner?
Yes
No
Are you currently enrolled in a health insurance plan that covers you while overseas?
Yes
No
What insurance coverage do you currently have?
Do you have medical evacuation insurance?
Yes
No
Departure Date from United States:
Return Date to United States:
Countries AND cities to be visited in order of visits
Arrival Date
Departure Date
A.
Have you travelled outside the United States before?
Yes
No
If yes, where and when?:
B.
Will you be:
Yes No
Visiting ONLY major cities? If no, explain:
Staying ONLY in Hotels? If no, explain:
Visiting friends and family?
Ascending to high altitudes (>7,000 ft. or 2,300 meters) in the mountains.
Working in the medical or dental field with exposure to blood or other body fluids?
Working with exposure to animals?
Potentially having sexual contact with new partners?
Engemann Student Health Center • 1031 W. 34th Street, Los Angeles, California 90089-3261 • 213-740-9355
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