Senior Living Facility COVID-19 Daily Visitor Form
Date
Time In
Visitor Name
Phone Number
Resident Visiting
Screening Questions
In the last 14 days, have you:
Been in contact with a COVID-19 positive individual
Traveled outside the country/state/province
Experienced any COVID-19 symptoms
If yes, please describe
Temperature Reading
Temperature (°C/°F)
Signature
Visitor Signature
Staff Initials