Covid Screening Questionnaire for Visitors

Covid Screening Questionnaire for Visitors
This form is designed in an effort to reduce the risk of COVID-19 exposure and to protect the public, as well as our employees, from the COVID-19 pandemic.
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Visitor Name
First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Person/Department Visiting
I am not presenting any of the COVID-19 symptoms, such as fever, shortness of breath, dry cough, runny nose, sore throat.
I have not been in contact with a person who has been diagnosed with COVID-19 within the past 14 days.
I have not travelled outside the country within the past 14 days.
I understand the importance and significance of social distance and hygiene measures.
Visitor's Signature
Clear
Should be Empty: