Visitor Health Assessment Name First Name * Last Name * ID Number * Cell Phone Number * Company Name * Company Address * Reason for visit * Appointment Collection Delivery Other Questions to be answered truthfully. Provide details in Comment Column if needed. In your opinion are you healthy and in a fit state to enter our premises? * Yes No Have you been in contact with any person that has COVID-19? * Yes No Does any body in your immediate family have or display symptoms of COVID-19? * Yes No Have you visited a medical doctor or clinic recently? If so why? * Yes No Are you aware of our company rules and what action to take should you be infected or suspect that you have come into contact with someone who has COVID-19? * Yes No Are you aware of our company guidelines on social distancing and hygiene practices? * Yes No Will you adhere to our guidelines and practice safe COVID-19 principles? * Yes No Do you have the necessary Protective Personal Equipment available? * Yes No Have you been instructed on the use of Protective Personal Equipment? * Yes No As far as you are aware do you consider this information true and correct? * Yes No Temperature * Cleared to enter? * Yes No Time In * FCL Staff *
