Request for Travel Information

Home Search News Events Publications Local Stats Links Careers Contact Us About Us

Travelling

Request For Travel Information

Please complete one form per trip and per family.

(Note: Please review the Disclaimer for Online Submission before completing this online form.)

Grey Bruce Health Unit

101 17^th Street East

Owen Sound, Ont., N4K 0A5

Phone #: 519-376-9420 or 1-800-263-3456

Fax #: 519-376-7782

OFFICE USE ONLY:

Date received at Health Unit: _______________________

NOCUD:________

(Review PHIPA statement on back of form when taking information over the phone and initial)

Package completed by:

____________________ on__________

This service is for residents of Grey and Bruce Counties only.

Traveller #1	Name:
	Male Female	Birth date: (YYYY/MM/DD)

Traveller #2	Name:
Same household only	Male Female	Birth date: (YYYY/MM/DD)

Traveller #3	Name:
Same household only	Male Female	Birth date: (YYYY/MM/DD)

Traveller #4	Name:
Same household only	Male Female	Birth date: (YYYY/MM/DD)

Medical Conditions: check all that apply

diabetes disability

heart disease pulmonary disorder

pregnancy stomach disorder

Travel Category: check all that apply

Affluent Tourism (first class hotel, urban centres, resort, etc.)

Rural/Safari/Hiking

Health Care Worker

Veterinarian/Animal Handler/Spelunker

Missionary/CUSO

Cruise – Please list Ports of Call below

Other

Travel Itinerary: List the countries you will be visiting in order of travel.

COUNTRY/ (Ports of Call)	PROVINCE/STATE REGION/CITY URBAN/RURAL	DATE OF ARRIVAL (YYYY/MM/DD)	LENGTH OF STAY (days in each location)

Please check þ one of the following:

I WILL PICK UP MY PACKAGE AT THE HEALTH UNIT

OWEN SOUND SITE WALKERTON SITE

101 17^th Street East 30 Park Street

PLEASE MAIL MY PACKAGE

Name and Mailing Address - Please provide, even if you are picking up your package.

Recipient Name:
Address1:
Address2:
City/Town:
Postal Code:
Home Telephone:
Work Telephone:

This information is being collected pursuant to the Health Protection and Promotion Act, R.S.O.1990, c.H.7 and will be retained, used, disclosed and disposed of in accordance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.M.56, the Personal Health Information Protection Act, 2004, S.O.c.3 and all applicable federal and provincial legislation and regulations governing the collection, retention, use, disclosure and disposal of information. Any questions regarding this collection may be directed to the Director of Finance and Administration at 101 17^th Street East, Owen Sound, Ontario, N4K 0A5, 519-376-9420.

Disclaimer for Online Travel Form:
Be advised that although safeguards are in place to protect your privacy using this online process, there is some risk associated with providing your personal information in this manner. Since this form is sent via unsecured email, there is the possibility of this information being intercepted by 3rd parties during its transmission.
Please use the Privacy Statement and Disclaimer links below to review detailed privacy information. The information collected on this form will be kept confidential and is used to generate a travel information package for your use in pre-travel planning.