COVID-19 Visitor Diligence Questionnaire In addition to the screening process below, upon arrival visitors will be subject to temperature checks and will be required to wear masks and practice Social Distancing as noted throughout the facility.Company name*Person's name*Purpose for the visit*Date of visit*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is this an "essential" visit?*NoYes*Visits should be limited to those things that are essential to our operations or a current project.Have you or anyone in your household or business been exposed to anyone who has COVID-19?*NoYesHave you or anyone in your household or business been outside of the United States in the last three months?*NoYesWhen did you/they travel and when did you/they return home?*Have you experienced any of the following symptoms in the last 14 days?* Fever Cough Difficulty breathingHas anyone in your household or business experienced any of the following symptoms in the last 14 days?* Fever Cough Difficulty breathingSignature of person attending*
