Visitor Questionnaire - Covid19

Date *

Estimated Time of Arrival *

Name of Person / Department Visiting *

Visitor / Contractor First Name *

Vistor / Contractor Last Name *

Visitor / Contractor Email *

Used to send visitor confirmation email of survey responses.

Visitor / Contractor Phone No. *

So we can reach visitor in case of change of plans.

I am a confirmed case of COVID-19 (Corona Virus) *

Yes

In the last 14 days - I have had close contact with a confirmed case of COVID-19 *

Yes

In the last 14 days - I have had close contact with someone who has returned from ANY International destination *

Yes

Have you had close ontact with or cored for someone diagnosed with COVID-19 within the last 14 days? *

Yes

If you are human, leave this field blank.