Hospital Visitor Vaccination Assessment Form
Use this form to assess a visitor’s vaccination status and basic visit screening before entering the hospital.
Visitor Information
Visitor Full Name
*
First Name
Last Name
Visitor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Visitor Email Address
*
example@example.com
Visit Details
Hospital/Department Being Visited
*
Please Select
General Medicine
Surgery
Pediatrics
Maternity
ICU
Emergency
Other
Patient Relationship or Purpose of Visit
*
Family
Friend
Caregiver
Clergy
Delivery/Drop-off
Other
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Visit Time
*
Hour Minutes
AM
PM
AM/PM Option
Vaccination Assessment
Vaccination Status
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
Date of Most Recent Vaccination
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: