Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Untitled Page
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To be completed by all visitors including maintenance personnel
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NAME:
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JOB TITLE:
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EMPLOYER:
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PURPOSE OF VISIT :
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Have you ever had, or are you known to be a carrier of, enteric fever, typhoid or paratyphoid ?
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Have you now, or have you over the last seven days, suffered from diarrhea and/or vomiting ?
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Have you been abroad in the last three weeks?
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If YES, were you ill ?
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At present are you suffering from:
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a. Skin trouble affecting hands, arms, or face?
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b. Boils, sties, or septic fingers?
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c. Discharge from eye, ear, or gums/mouth?
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Do you suffer from:
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a. Recurring skin or ear trouble?
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b. A recurring gastrointestinal disorder?
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If you answered YES to any of the above questions please provide below any further details, which may assist in determining your suitability or not to enter food-handling areas.
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I declare that the answers to these questions and any additional information supplied are accurate to the best of my knowledge.
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Date
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OFFICIAL USE:
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I declare that I have reviewed the responses on the visitor's health questionnaire and determined that the applicant is:
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Approved to enter food handling areas.
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NOT approved to enter food-handling areas.
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Qc name and Signed
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Date
