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