VISY Visitor Health Screening Form

Visitor Health Screening Form
Version: 1.5 | Implemented Date: 16.03.2020 | Reviewed & Approved by: Adrian Dalgleish

In an effort to assist in prevention and spread of novel coronavirus (COVID-19) in our community and reduce the risk of exposure to our staff and visitors, we are conducting a simple screening checklist for all visitors. Your participation is important to help us take precautionary measures to protect yourself and others at this site.
Visitor’s name:
Personal contact number (Mobile number/Home):
Time

: Hour Minutes AM/PM Option
Date :

Month Day Year
Date
Whom visiting?
Organisation of visitor (If applicable):
Have you confirmed with your site contact that your visit to site is business critcial and is still to proceed as planned

Yes No
Do you have any of the following symptom(s), please tick the relevant box(es)

No symptom Yes, tick below Fever Dry cough Body aches Headaches Sore throat Runny nose Tiredness Shortness of breath
2 Have you, or a direct member of your household travelled internationally within the previous 14 days?

Yes No
If yes, please indicate the country(s) or area(s) :
Have you or a direct member of your household, had direct contact with a person with suspected or confirmed coronavirus symptoms

Yes No
If yes, please indicate the affected country(s) or area(s) :
If you have answered "Yes" to any of the above, we ask that your visit be rescheduled to a phone or video conference and ask that you refer to the he health.gov.au for additional information about coronavirus ( COVID-19)

I acknowledge that the responses I have provided above are a true and accurate.
Signature (VISITOR):

Clear
Date:

Month Day Year
Date
*Note: Information captured is used for contact tracing if required
Should be Empty: