GFR001 Visitors questionnaire V4

• Conducted on

  Date

• Name

• Company

• Purpose visit

• Site Contact

Have you ever suffered from?

• Typhoid, Paratyphoid, Salmonella, Shigella, E coli (0157)?

  Yes

  No

  N/A

• If YES, Please provide details:

• Hepatitis or Jaundice

  Yes

  No

  N/A

• If YES, Please provide details:

• During the last 48 hours have you suffered from : nausea, vomiting or diarrhoea or taken anti-diarrhoeal drugs

  Yes

  No

  N/A

• If YES, Please provide details:

Are currently suffering from

• Productive cough or sneezing

  Yes

  No

  N/A

• If YES, Please provide details:

• Acne, boils, septic cuts or sores

  Yes

  No

  N/A

• If YES, Please provide details:

• Runny ears /sticky or sore eyes

  Yes

  No

  N/A

• If YES, Please provide details:

• Scaling skin condition on the hands forearms or face

  Yes

  No

  N/A

• If YES, Please provide details:

• Are you currently suffering or have suffered from Hepatitis or Jaundice within the last 7 days

  Yes

  No

  N/A

• If YES, Please provide details:

• Have you been outside the UK within the last 3 months?

  Yes

  No

  N/A

• If YES, Please provide details:

• Have you suffered from any illness since return if you have been out of the UK?

  Yes

  No

  N/A

• If YES, Please provide details:

COVID – 19 health screening

• Are you currently suffering from?

  Yes

  No

  N/A

• Dry cough

  Yes

  No

  N/A

• High Temperature

  Yes

  No

  N/A

COVID – 19 symptoms

• Have you, or do you suspect you have had COVID19 in the last 14 days?

  Yes

  No

  N/A

• Is anyone in your household showing symptoms or has been confirmed as having COVID19 in the last 14 days?

  Yes

  No

  N/A

• Have you been in close proximity with anyone who has been confirmed, or who has shown symptoms of COVID19, in the last 14 days?

  Yes

  No

  N/A

• Any ‘YES’ answer above will mean access to site will not be permitted

If all answers above are ‘No’ please proceed to the questions below:

• I will highlight to my host immediately, if I start to show symptoms of a dry cough and/or a fever while on site?

• I will keep a social distance from all personnel and other visitors and contractors on site?

• I will wash my hands thoroughly and regularly during my time on site?

• I will wash my hands before and after touching my face?

• I have read and understood the above standards

• Signed:

  Sign

• GrowUp authorising signature:

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