Temperature Screening Consent Form
Please provide your information and consent to participate in temperature screening for health and safety purposes.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Screening Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Screening Location (Site/Building)
*
Recorded Temperature (°C or °F)
*
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Sore throat
Loss of taste or smell
None of the above
Other
Have you been in close contact with anyone diagnosed with a contagious illness (e.g., COVID-19) in the past 14 days?
*
Yes
No
Name of Person Conducting Screening
Signature
*
Submit Consent
Submit Consent
Should be Empty: