COVID-19 Health Screening Visitor Log
Date
Visitor Name
Phone Number
Organization / Company
Person Visiting / Purpose
Time In
Time Out
Do you have any of the following symptoms: fever, cough, difficulty breathing, sore throat, or loss of taste/smell?
Yes
No
Have you had close contact with a confirmed COVID-19 case in the past 14 days?
Yes
No
Have you traveled internationally or been in a COVID-19 outbreak area in the last 14 days?
Yes
No
Visitor Signature
Staff Initials