HomeCOVID-19Visitor Screening

COVID-19 (Coronavirus)
Visitor Screening

Please note All fields are mandatory. One form per visitor must be completed.

Full name of visitor*
Company name*
Email ID*
Date of planned visit*
MM slash DD slash YYYY
Primary contact at location*
Location*
Purpose of visit*
Have you had any known symptoms of COVID-19, including without limitation fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, or diarrhea in the last 14 days?*
- Yes
- No
1.
Have you been in close physical contact with (within approximately 6 feet for more than a transitory period of time) anyone with COVID-19 and/or known symptoms of COVID-19 (including anyone who developed such symptoms up to 48 hours after your close physical contact) in the last 14 days AND you are not fully vaccinated (two weeks after second dose of 2-dose series such as Pfizer or Moderna, or two weeks after single-dose vaccine, such as Johnson & Johnson)?*
- Yes
- No
2.
Have you, anyone in your household, or anyone you have been in close physical contact with travelled internationally in the last 14 days AND you are not fully vaccinated?*
- Yes
- No
3.
Have you or anyone in your household been in close physical contact with anyone who is in quarantine, isolation, or is suspected of being exposed to or contracting the COVID-19 virus in the last 14 days AND you are not fully vaccinated?*
- Yes
- No
4.
Agreement*
- I certify the above information is true and correct to the best of my knowledge and that I will immediately report if I begin to experience COVID-19 symptoms during my visit.
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

COVID-19 (Coronavirus) Visitor Screening

COVID-19 (Coronavirus)
Visitor Screening