Security Screening Form
Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Visitor Type
Member
Vendor
Employee
family Member
Other
Name of the Person You Visiting
First Name
Last Name
Company Name
Your Temperature
Are you fully vaccinated?
Yes
No
Have you traveled internationally in the last month?
Yes
No
Symptoms:
Fever
Cough
Shortness of breath
Difficulty Breathing
Chills
Muscle Pain
Headache
Sore Throat
New Loss of Taste
New Loss of Smell
Fatigue
Diarrhea
Vomiting
Are you experiencing any of the symptoms above?
Yes
No
Have you had a Covid test in the last 7 days?
Yes
No
Do you have a mask?
Yes
No
Submit
Should be Empty: