Cleveland Integrity Services

First Name(*)

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Last Name(*)

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Email(*)

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Phone(*)

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Date(s) of Visit(*)

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Staff you will visit(*)

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Purpose of the Visit(*)

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Have you or anyone in your household been in contact with anyone with a confirmed case of COVID-19 within the last 14 days?(*)

NoYes

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Are you running a body temperature of 100.3 or higher?(*)

NoYes

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Today’s temperature (°F)(*)

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Are you experiencing any of the following symptoms?

Difficulty breathing or shortness of breath(*)

NoYes

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New onset of cough or worsening of chronic cough(*)

NoYes

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Sore throat or painful swallowing(*)

NoYes

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Headache, muscle, joint or body aches(*)

NoYes

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Fever or chills(*)

NoYes

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Loss of sense of taste or smell(*)

NoYes

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Conjunctivitis (pink eye)(*)

NoYes

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Congestion or stuffy nose(*)

NoYes

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Nausea, vomiting, diarrhea, or unexplained loss of appetite(*)

NoYes

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Feeling unwell, fatigue or severe exhaustion(*)

NoYes

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Signature(*)

Sign Above

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If you answered “YES” to any of these questions, please advise the receptionist and await further instructions – DO NOT proceed further into the facility.

If you answered “NO” to all questions, please submit the form to the receptionist for review and further instruction.

*Visitors are those individuals who are not a regular part of the Operations of this facility or on-site team and may include, but are not limited to the following: Project/contractor management, vendor reps, suppliers, deliver drivers, catering services, courier services, site support services (utility, septic, HVAC, etc.)

COVID-19 Screening for Visitors

Are you experiencing any of the following symptoms?