Annex C.

Travel History, Places Visited, and Events Attended Form

HISTORY OF TRAVEL, PLACES VISITED, AND EVENTS ATTENDED BY THE SUSPECTED COVID-19 CASE

Instructions: Obtain information on DAILY travel history, and events attended by the case for the past 14 DAYS PRIOR ONSET OF ILLNESS. Fill out
ALL items that are applicable and use additional sheets if needed. If the suspected case does not have any local or foreign travel history and did not
visit the specific type of place, write N/A in the first cell under Day of Onset of Illness in the table.

Name:____________________________________ Age: ______ Sex: Male Female

Home Address: Home Telephone Number: Mobile Number:

I. TRAVEL HISTORY
A. Domestic and International Travel by Air and Sea
Days from Onset Date Name of Flight Carrier Flight No. / Vessel No. Route
of Illness (Plane)/ Sea Vessel
1 Passenger Crew
2 Passenger Crew

B. History of Land Transportation

Days from Date Route Type of Vehicle Aiconditioned Estimated No. of Persons
Onset of Illness
1 Bus (Name:_____________________) Yes
Train (Name:____________________) No
Public Utility Cars
Public Utility Jeepney/ Tricycle/Motorcycle

II. PLACES VISITED

A. Accommodation
Days from Date Name and Address of Duration of Stay Type of Accommodation Airconditioned
Onset of Illness Accommodation (# of hours, guest or worker)
1 Number Guest Yes Airconditioned
Of Hours: Worker No Non-airconditioned
Household contact

B. Food Establishment
Days from Date Name and Duration of Stay Type of Food Establishment Airconditioned
Onset of Address of Food (# of hours, guest or worker)
Illness Establishment
1 Number Dinner Fast-food restaurant Yes
Of Hours: Food delivery staff Buffet No
Worker Bar
Carinderia/diner
Others (pls. specify________)

C. Store
Days from Date Name and Duration of Stay Type of Store
Onset of Address of (# of hours, guest or worker)
Illness Store
Number Customer Public market Airconditioned grocery shop
Of Hours: Worker Non-airconditioned grocery shop Convenience store
Sari-sari store Hardware
Mall Others (Pls.specify:________)

D. Health Facility
Days from Onset Date Name and Address of Duration of Stay Type of Health Facility
of Illness Health Facility (# of hours, patient or HCW)
1 Number Health worker Government hospital Private hospital
Of Hours: Patient Stand-alone clinic Stand-alone laboratory
Rural Health Unit S Health Center
Barangay

E. Workplace
Days from Onset of Date Name of Company Address of Company Work shift during the day of
Illness exposure
1

III. EVENTS ATTENDED

Days from Onset of Date Type of Event Location of Event Tiime of the Event Number of Hours
Illness (Morning, Afternoon, Spent in the Event
Evening)
1
2