COVID-19 Staff and Visitor Record Form

COVID-19 Staff and Visitor Record Form
Under current public health advice we are required to establish and maintain a register of every visitor. Please help to protect your health and that of other members of the community by providing accurate and legible information.
Visit Date
MonthDayYear
Date
Hour MinutesAM/PM Option
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Have you been in contact with a person who travelled overseas in the past 14 days?
YesNo
Have you been in close contact with a confirmed COVID-19 case in the past 14 days?
YesNo
Are you suffering from any of the following symptoms: fever, respiratory illness, cough, sore throat, shortness of breath?
YesNo
If you've responded as "Yes" to any of the above-mentioned questions please do not enter the building and contact the responsible personnel.
I acknowledge that all given information is accurate and I agree to follow the directions for preventing the spread of COVID-19.
Agree
Signature
Clear
Should be Empty: