![[COMPANY LOGO]
DOC NO 001
REV DATE 2021/04/30
ISSUED 2020/05/01
PAGE 1 of 1
SECTION RISK MANAGEMENT
SUB-SEC HSE GUIDELINES
SUBJECT VISITOR SCREENING QUESTIONNAIRE
You are important to us and in order to limit the spread of COVID-19 we would appreciate it if you
could disclose the following information. All information will be held in confidence.
Name: Surname:
Contact Number Contact Email:
Company/Organization:
I
hereby declare the following:
Visitor Declaration Questions Yes No
1 Have you travelled in the last 21 days?
If, yes where to?:
2 Have you been exposed to someone who has the COVID-19 virus?
3 Have you experienced at least one of the following symptoms recently
a Cough
b Sore throat
c Shortness of breath
d Redness of eyes
e Body aches
f Loss of smell
g Loss of taste
h Nausea
i Vomiting
j Diarrhoea
k Fatigue
l Weakness
m Tiredness
n Fever (must be equal to or below 37.5°C (measured))
o Fever or history of fever (subjective) over the past 21 days
4 Have you attended a health care facility where patients with COVID-19 infections
are being treated?
5 Have you been hospitalised recently with severe pneumonia?
6 Do you currently have flu like symptoms?
To help limit the spread of infection, should you have answered yes to any of the above questions we
advise that you refrain from coming onto site and make arrangements to continue with the meeting
telephonically or using any available technology.
Temperature as measured by the screener (degrees C)](https://image.slidesharecdn.com/covid19visitorscreening-200728115428/85/Module-5-Visitor-Information-Form-1-320.jpg)
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Module 5- Visitor Information Form
- 1. [COMPANY LOGO] DOC NO 001 REV DATE 2021/04/30 ISSUED 2020/05/01 PAGE 1 of 1 SECTION RISK MANAGEMENT SUB-SEC HSE GUIDELINES SUBJECT VISITOR SCREENING QUESTIONNAIRE You are important to us and in order to limit the spread of COVID-19 we would appreciate it if you could disclose the following information. All information will be held in confidence. Name: Surname: Contact Number Contact Email: Company/Organization: I hereby declare the following: Visitor Declaration Questions Yes No 1 Have you travelled in the last 21 days? If, yes where to?: 2 Have you been exposed to someone who has the COVID-19 virus? 3 Have you experienced at least one of the following symptoms recently a Cough b Sore throat c Shortness of breath d Redness of eyes e Body aches f Loss of smell g Loss of taste h Nausea i Vomiting j Diarrhoea k Fatigue l Weakness m Tiredness n Fever (must be equal to or below 37.5°C (measured)) o Fever or history of fever (subjective) over the past 21 days 4 Have you attended a health care facility where patients with COVID-19 infections are being treated? 5 Have you been hospitalised recently with severe pneumonia? 6 Do you currently have flu like symptoms? To help limit the spread of infection, should you have answered yes to any of the above questions we advise that you refrain from coming onto site and make arrangements to continue with the meeting telephonically or using any available technology. Temperature as measured by the screener (degrees C)
- 2. Please note the following which will apply to all meetings; We have a “no handshaking policy” in place at this point in order to mitigate the spread. We encourage you to make use of the hand sanitisers that we have made accessible. The meeting attendance register must be completed by all meeting attendees. Phyisical distancing will be adhered to during meetings DECLARATION I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. I further undertake to inform THE PERSON I AM VISITING should I be diagnosed with COVID-19 within the next 14 days so as to facilitate contact tracing. Your cooperation is appreciated. Signature: Date: