Attachment C_COVID-19 Traveler Information Form.pdf

COVID-19 Traveler Information Form AUTEC, Andros Island, Bahamas

Traveler’s Name: Travel Start Date:

Command/Company Name: Mode of Transportation to AUTEC Terminal:

Departure Location: Arrive at AUTEC Date:

AUTEC Site Location (Site 1, Site 2, other): Departure from AUTEC Date:

Reason for Visit (please provide detailed description of the visit):

RESTRICTION OF MOVEMENT (ROM)

Please check all boxes that apply.

ROM ASD (14-day quarantine on Andros Island, Bahamas)

ROM Home (14-day quarantine at home station)

ROM Sequester (Bubble-to-Bubble Plan)

Exempt - due to COVID-19 vaccine regimen completion

Exempt - due to certified as recovered from being confirmed COVID-19 positive

If one of the Exempt boxes are checked, provide the date of completion of the vaccination regimen; or the date of COVID-19 onset; or the date of positive COVID-19 test results; and the date of recovery from your COVID-19 infection.

Certification information must be provided to AUTEC Medical Services.

To the best of your knowledge, the Traveler has not been around anyone that tested positive for COVID-19 or was sick?

No Yes If yes, please provide details.

Sponsor’s/Supervisor’s Signature:

This section applies ONLY for non-ASD business travel.

For ASD personal leaving AUTEC on other than business travel.

Please answer the following questions:

What is your destination? Where are you staying during your travel (provide names of all hotels and locations)?

What is your means of travel (check all that apply and provide details as needed)?

Personal vehicle

Rental – please provide the name of the agency and location:

Flying – please provide the name of the airline:

What precautions are you taking during your travels?

Traveler’s Signature:

Please provide this information as soon as possible and prior to your travel start date.

Your attention to this matter is greatly appreciated.

Return this completed form to Kate Laurent at Katherine.laurent.ctr@navy.mil. Please provide a copy to your manager and the Base Ops Group Manager.

DC 1271 (Rev 03/21)