Screening Checklist for Visitors
Name of the Individual
1. Has the individual washed his/her hands or used antiseptic?
Yes No (please ask her/him to do)
2. Which of the following symptoms does the individual have?
Fever Cough Shortness of Breath Persistent Pain in the Chest
- 3. For employees – check the temperature and enter the result.
- 4. Has the individual contacted with people that were infected, suspected or diagnosed with COVID-19?
- 5. Additional Notes
Remind and ask individuals to
- Wash their hands or use antiseptics
- Not shake hands or contact physically
- Wear face masks in the building
Please fill this form and submit