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*
Date Format: MM slash DD slash YYYY
Primary contact at location*
Location*
Purpose of visit*
Have you or anyone in your household had any flu-like symptoms (e.g. sore throat, fever, headache, runny nose, cough, or other respiratory issues) in the last 72 hours without the aid of fever-reducing or other symptom-masking medicines?*
- 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 flu-like symptoms (including anyone who developed flu-like symptoms up to 48 hours after your close physical contact) in the last 14 days?*
- Yes
- No
2.
Have you, anyone in your household, or anyone you have been in close physical contact with travelled internationally or to New York, New Jersey, or Connecticut in the last 14 days?*
- 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?*
- 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 flu-like symptoms during my visit.