First Name: Last Name:
Phone
Temperature (in °F)
Visitor or Employee? VisitorEmployee
Note: The information above will be used only to determine risk and your ability to work or visit. Your personal answers to this questionnaire are confidential and will be stored in your medical file.
If the answer is “yes” to any of the questions or your temperature exceeds 100.4° F, you may not return to work or visit the suite until you satisfy the following…