Site Access Medical Screening Form
Complete this form before site entry so access can be reviewed based on the required screening information.
Visitor Information
Full Name
*
First Name
Last Name
Company or Organization Name
*
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Site Access Screening
Visit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Destination / Site or Department
*
Current Body Temperature (°C)
Are you currently experiencing any symptoms that may affect site entry?
*
Yes
No
Entry Status and Acknowledgment
Entry Status
*
Cleared to enter
Needs review
Denied entry
Acknowledgment
I confirm the information provided is accurate and I will follow site entry rules
Submit
Should be Empty: