Surveypoint

Q1

Visitor Name

First Name

Q2

Visitor Name

Last Name

Q3

Visitor Company Name

Q4

Visitor Phone

Q5

Visitor Email

Q6

Department to Visit

Q7

Person to Visit

First Name

Q8

Person to Visit

Last Name

Q9

Purpose of Visit

Q10

Have you been vaccinated for COVID-19?

Yes

No

Q11

Is it first dose and second dose?

I was vaccinated for first dose only

I am fully vaccinated (first and second dose)

Q12

Did you travelled outside the state or country in the last 14 days?

Yes

No

Q13

Have you been exposed to someone with COVID-19 for the last 14 days?

Yes

No

Q14

Do you live with someone who tested positive for COVID-19?

Yes

No

Q15

Authorized Person approved this visit

First Name

Q16

Authorized Person approved this visit

Last Name

Q17

Position/Title

Q18

Signature

Q19

Date Signed

Date

Office Visit Scheduling -Form Fill

Visitor Name

Visitor Name

Visitor Company Name

Visitor Phone

Visitor Email

Department to Visit

Person to Visit

Person to Visit

Purpose of Visit

Have you been vaccinated for COVID-19?

Is it first dose and second dose?

Did you travelled outside the state or country in the last 14 days?

Have you been exposed to someone with COVID-19 for the last 14 days?

Do you live with someone who tested positive for COVID-19?

Authorized Person approved this visit

Authorized Person approved this visit

Position/Title

Signature

Date Signed