COVID-19 Questionnaire Template for Visitors and Vendors
*IMPORTANT: This form aims to provide a safe environment to visitors, vendors, families and employees inside our facility. Please answer the questions below accurately to minimize the risk of COVID-19 exposure across our facility.
Date of visit
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your purpose of visit?
Visitor
Vendor
Other
Full Name
First Name
Last Name
Company Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please name the hosting person
First Name
Last Name
In the last 14 days;
Rows
Yes
No
Have you had close contact with or cared for someone who has been
diagnosed with COVID-19 or suspected?
1
2
Have you traveled to any country/state for which has a Travel Health Notice for COVID-19?
3
4
Have you
had close contact with anyone who visited
to any country/state for which has a Travel Health Notice for COVID-19?
5
6
Have you experienced any of the following symptoms: high fever,
cough, sore throat, or shortness of breath?
7
8
Signature
By submitting this form you are certifying that you are responding to these questions honestly and to the best of your ability.
Submit
Should be Empty: