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(COMPANY) COVID-19 Questionnaire: If You Have Any Questions or Concerns, Please Contact

This document provides a disclaimer stating that the information contained is for informational purposes only and does not create a legal relationship. It also contains a voluntary COVID-19 questionnaire for visitors and contractors of [COMPANY]. The questionnaire asks for name, company, date, recent travel history including countries and airports, COVID-19 symptoms experienced in the past 3 weeks, and contact with anyone showing symptoms or diagnosed with COVID-19. Contact information is provided for any questions.

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84 views1 page

(COMPANY) COVID-19 Questionnaire: If You Have Any Questions or Concerns, Please Contact

This document provides a disclaimer stating that the information contained is for informational purposes only and does not create a legal relationship. It also contains a voluntary COVID-19 questionnaire for visitors and contractors of [COMPANY]. The questionnaire asks for name, company, date, recent travel history including countries and airports, COVID-19 symptoms experienced in the past 3 weeks, and contact with anyone showing symptoms or diagnosed with COVID-19. Contact information is provided for any questions.

Uploaded by

ahmed4dodi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DISCLAIMER OF LIABILITY: This document was prepared by the Society of Chemical Manufacturers and Affiliates (SOCMA) and is disseminated

for informational and educational purposes only. This information is not intended as legal guidance and does not create any legal relationship
or responsibility between SOCMA and user. Nothing contained herein is intended to revoke or change the requirements or specifications of
individual manufacturers or local, state and federal officials that have jurisdiction in your area. The user is responsible for assuring compliance
with all applicable laws and regulations.

[COMPANY] COVID-19 Questionnaire


Safety is a core value of [COMPANY] and as such the health and well-being of our
employees, visitors and contractors is paramount.

Due to the unprecedented concern for the COVID-19 (Coronavirus) [COMPANY] is


requesting all visitors and contractors fill out this voluntary survey before being granted
access to any of our facilities.

Name: ___________________________________________

Company: _______________________________________

Date: ____________________________________________

1. Have you been out of the country in the past three weeks? If yes, which countries and
airports did you travel through?

2. Have you experienced any of the following symptoms in the past three weeks? If yes,
please check associated box.
a. Fever of 100.4° or higher
b. Cough
c. Shortness of Breath
d. Persistent Pain or Pressure in the chest

3. Have you been in close contact with anyone showing any of these symptoms or
anyone who has been diagnosed with COVID-19 (Coronavirus)?

If you have any questions or concerns, please contact:

Company Contact
Company Name
Company Contact Title
Phone Number
Email

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