C-19 Questionnaire

Access to this facility is limited to those that do not have signs or symptoms of COVID-19.

Name*

First NameLast Name

Date of Visit*

Date

Company*

Company/Reason you are visiting today *

Please answer the following questions:

Do you currently have, or have you experienced any of the following cold or flu-like symptoms within the past 14 days: fever, cough, shortness of breath, difficulty breathing, sore throat, body aches, or lack of taste or smell?*

YesNo

Have you traveled outside of the country within the past 14 days?*

YesNo

Have you had direct contact within the last 14 days with a person confirmed or suspected to be positive with COVID-19?*

YesNo

Are you living with or caring for a family member with COVID-19?*

YesNo

Are you in a 14 day period of isolation as directed by a healthcare provider?*

YesNo

It is up to YOU to practice good infection prevention to keep building occupants and staff safe. During your visit, you agree to:

Leave premises if you are feeling sick
Always wear a mask or face covering
Wash or disinfect your hands frequently
Stay at least six (6) feet from other people
Cover your cough and sneezes
Limit touching of surfaces to only what is necessary

By signing below, you CONSENT to the temperature screening and recording below, and AGREE to the above infection prevention measures:*

A no-contact thermometer will be used to take your temperature. Please choose your temperature range below. Readings of or exceeding 100.4 degrees Fahrenheit will NOT be allowed to enter. Up to two (2) retakes will be permitted.*

Temperature was less than 100.4F; ENTRY ALLOWEDFever equal to or higher than 100.4F; ENTRY NOT ALLOWED

COVID-19 Questionnaire