180 THOR COVID-19 Visitor Questionnaire

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To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

Email *

Appointment Date *

YYYY

First and Last Name *

Phone Number *

What floor will you be visiting? *

Have you returned from any of the High-Risk Countries or other high-risk States within the last 14 days? *

Yes

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *

Yes

Have you been in close contact with anyone who has traveled within the last 14 days to one of the high risk Countries or other States? *

Yes

Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)? *

Yes

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