Health Declaration Form

Screen visitors, staff or students before they enter a building or event. Questions cover recent travel, illness in the past month, respiratory symptoms, contact with confirmed cases and animal exposure, ending with a signed statement. Reception and security teams keep a clear entry log.

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Full name

Nombre

Apellido

Sex

Female Male

Age

Contact number

Email address

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Countries you worked in, visited or transited through in the past 14 days

Cities you worked in, lived in or transited through in the past 14 days

Have you been unwell in the past 30 days?

Yes No

If yes, describe the illness and which hospital you attended

In the past 14 days, have you had fever, a cold, cough, sore throat, loss of smell or taste, muscle pain, headache or breathing difficulty?

Yes No

If yes, tick which ones

Fever Cough Sore throat Loss of smell or taste Muscle pain Headache Difficulty breathing

In the past 14 days, have you had close contact with a suspected or confirmed COVID-19 case?

Yes No Not sure

If yes, describe the circumstances

In the past 14 days, have you been in contact with farm or wild animals?

Yes No

If yes, describe the circumstances

Declaration of truthfulness

Date

Signature

Sign here

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