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