Visitors

Screening Checklist for Visitors

Following questions will be asked all visitors entering the building.

Full Name

Phone Number

Name of the person you are meeting

Purpose of Visit

Are you showing any signs of one or more of the following symptoms?

YES: Temperature greater than 100.4 degrees Fahrenheit (38 degrees Celsius) or higher

YES: Cough, shortness of breath or difficulty breathing

YES: Chills, repeated shaking with chills

YES: Muscle Pain or Tiredness

YES: Headache, sore throat and/or loss of taste of smell

None

If YES any of these symptoms, please *** RESTRICT *** the visitor from entering the building

Is the information you provided true and correct to the best of your knowledge?

Yes

Heath Screening completed by

Any additional comments?