COVID-19 Visitor Health Declaration
For Office Buildings
Full Name
Date of Visit
Contact Number
Email Address
Company/Organization
Person to Visit / Department
Health Screening
Have you experienced any of the following symptoms in the past 14 days: fever, cough, shortness of breath, loss of taste or smell, sore throat?
Yes
No
Have you tested positive for COVID-19 in the past 14 days?
Yes
No
Have you been in close contact with a confirmed or suspected COVID-19 case in the past 14 days?
Yes
No
Have you traveled internationally or to an area with known COVID-19 transmission in the past 14 days?
Yes
No
Declaration & Signature
I declare that the information I have provided is true and accurate to the best of my knowledge.
Signature
Date
I agree to comply with the office’s COVID-19 safety policies.