COVID 19 Jobsite Visitor Questionnaire

• Project Name

• Visitor Name

• Date

  Date

• Reason for Visit

• Health and Safety Officer

• Location
  Address

• Employers should consider screening visitors. If a visitor answers “Yes” to any of the following sample questions, he/she should not be permitted to access the jobsite.

QUESTIONNAIRE

• 1. Have you been confirmed positive for COVID-19?

  Yes

  No

  N/A

• 2. In the last 72 hours, have you had: a new fever of 100.4°F, a new cough, shortness of breath, sore throat, new muscle aches or a loss of taste or smell?

  Yes

  No

  N/A

• 3. Have you or someone in your household or workplace been in close contact with a person who has signs of or has COVID-19?

  Yes

  No

  N/A

• 4. Have you been in close contact with any persons who have traveled and are also exhibiting acute respiratory illness symptoms?

  Yes

  No

  N/A

SIGN OFF

• Health and Safety Officer Signature

  Sign

• Visitor's Signature

  Sign