Vistor COVID-19 Self Screening Questionnaire

Vistor COVID-19 Self Screening Questionnaire

Updated as of 5/1/2020
The safety of our employees, supplier partners, customers, families and visitors remain C-Care’s overriding priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, C-Care Leadership is monitoring the situation closely and will periodically update company guidance based on current recommendations from the Centers for Disease Control and Prevention and the World Health Organization. Only business critical visitors are permitted in the facility at this time.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.
Visitor Name *

First Name Last Name
Visitor Company / Organization
Company / Organization
Phone Number

Area Code Phone Number
Email
example@example.com
Name of C-Care Host You Are Here to See *

First Name Last Name
Appointment Date / Time

Self Declaration by Visitor *

	Yes	No
Have you returned from any of the countries listed on Coronavirus FAQ within the past 14 days ?
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
Have you been in close contact with anyone who has traveled within the last 14 days to one of the countries listed (China, South Korea, Italy, Germany, UK, Brazil) ?
Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing) ?

If you answered “Yes” to question one, access to the facility will be DENIED

I certify to the best of my knowledge; this information is accurate.
Signature *

Clear
Should be Empty: