Visitor Screening Demo

Visitor Questionnaire

Please make note of your Entry Code upon completion of the form as it allows us to better service you.

This company requires all patrons to complete a screening before entering our location(s).

First Name

Last Name

Today's Date

Current Time

Whom are you here to visit?

What company are you with?

In the last two weeks have you been in contact with someone who tested positive for COVID-19? Yes No

In the past 14 days have you traveled outside of the following states: New Hampshire, Vermont, Maine, Massachusetts, Connecticut, or Rhode Island? Yes No

Do you currently have a temperature above 100.4°F? Yes No

Have you noticed any recent loss of taste or smell? Yes No

Are you experiencing any chills or muscle aches? Yes No

Are you experiencing any gastrointestinal symptoms such as nausea, vomiting, or diarrhea? Yes No

Are you experiencing any of the following symptoms?

Cough

Headache

Sore throat

Difficulty breathing

None of the above

We recommend that anyone answering yes to any of the screening questions above seek medical advice.

Title 1 Title 2 Title 3

Yes No

Checkbox1

Checkbox2

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Please make note of your unique entry code before submitting:

Entry Code

Thank you!

Please call upon arrival to be granted entry.

We thank you for your cooperation as we work to follow required guidelines to keep you safe.

What's Next?

Click below to view what you'll have access to on the client side.

Disclaimer: Neither IRISdesign nor your employer are liable for any issues arising from the use of this screening log.

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