Customer Wellness Survey

Screen a visitor's health status before arrival, covering possible exposures and recent symptoms, to help keep your space safe.

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Name

Nombre

Apellido

Phone Number

In the past 14 days, have you traveled outside of your hometown to any foreign country or area within the U.S. with a CDC Level 3 travel notice or similar State notice?

Yes No

In the past 14 days, have you been in close contact with someone (family, friend, or coworker) who returned from any foreign country or an area within the US with a CDC Level 3 travel notice or similar State notice?

Yes No

In the past 14 days, have you been in close contact (within six feet) of a person with a possible Coronavirus Infection?

Yes No

In the past 14 days, have you tested positive for or been infected with Coronavirus (COVID-19)?

Yes No

Do you currently have (or have you had in the past 14 days) any of the following symptoms: fever, bad cough, sore throat, runny nose, diarrhea, loss of smell/taste, shortness of breath, fatigue, vomiting or nausea.

Yes No

I, undersigned, agree with the following statements:

I confirm the information provided is true and complete

Date

Signature

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