Visitor Screening Questionnaire

Visitor Screening Questionnaire

Notice to be posted at all building entrances In an effort to protect our residents, clients, and patients, from illness we are screening visitors and volunteers. Please answer the following questions:
Within the past 14 days, I have traveled to a location where COVID-19 has been diagnosed or suspected.

YesNo
Within the past 14 days, I have been in close contact with persons who have traveled to a location where COVID19 has been diagnosed or suspected.

YesNo
Within the past 14 days, I have been sick with a cold or the flu.

YesNo
Within the last 7 days, I have had a fever.

YesNo
Within the last 7 days, I have had nausea and vomiting.

YesNo
Within the last 7 days, I have had diarrhea.

YesNo
I now have symptoms of a cold or flu.

YesNo
I now have a fever.

YesNo
Within the past 14 days, I have been around people who have been or are sick with colds or flu.

YesNo
I have been nauseated or have vomited or had diarrhea within the past week.

YesNo
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
IF YOU HAVE MARKED “YES” TO ANY OF THESE QUESTIONS, PLEASE POSTPONE YOUR VISIT FOR AT LEAST 14 DAYS FROM THE DAY YOUR SYMPTOMS BEGAN.

Thank you for your understanding

For more information on COVID-19 please visit www.DPH.ILLINOIS.GOV or call 1-800-889-3931
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