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    Visitor/Contractor Health Declaration Form ORM: Questions Circle Answer

    Uploaded by

    Lea Cardinez
    This document is a health declaration form for visitors and contractors to an Alfa Laval site. It collects personal information for compliance with COVID-19 policies and procedures. The site host is instructed to refuse access if the visitor answers yes to any question about potential COVID-19 exposure or symptoms. If all answers are no, the visitor is granted access. The questions ask if the visitor has tested positive for COVID-19, been exposed to someone with COVID-19, traveled internationally, been exposed to someone who traveled, been exposed to someone with flu-like symptoms, or is currently experiencing flu-like symptoms.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Visitor/Contractor Health Declaration Form ORM: Questions Circle Answer

    Uploaded by

    Lea Cardinez
    214 views2 pages
    This document is a health declaration form for visitors and contractors to an Alfa Laval site. It collects personal information for compliance with COVID-19 policies and procedures. The site host is instructed to refuse access if the visitor answers yes to any question about potential COVID-19 exposure or symptoms. If all answers are no, the visitor is granted access. The questions ask if the visitor has tested positive for COVID-19, been exposed to someone with COVID-19, traveled internationally, been exposed to someone who traveled, been exposed to someone with flu-like symptoms, or is currently experiencing flu-like symptoms.

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    health declaration form

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    This document is a health declaration form for visitors and contractors to an Alfa Laval site. It collects personal information for compliance with COVID-19 policies and procedures. The site host is instructed to refuse access if the visitor answers yes to any question about potential COVID-19 exposure or symptoms. If all answers are no, the visitor is granted access. The questions ask if the visitor has tested positive for COVID-19, been exposed to someone with COVID-19, traveled internationally, been exposed to someone who traveled, been exposed to someone with flu-like symptoms, or is currently experiencing flu-like symptoms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    214 views2 pages

    Visitor/Contractor Health Declaration Form ORM: Questions Circle Answer

    Uploaded by

    Lea Cardinez
    This document is a health declaration form for visitors and contractors to an Alfa Laval site. It collects personal information for compliance with COVID-19 policies and procedures. The site host is instructed to refuse access if the visitor answers yes to any question about potential COVID-19 exposure or symptoms. If all answers are no, the visitor is granted access. The questions ask if the visitor has tested positive for COVID-19, been exposed to someone with COVID-19, traveled internationally, been exposed to someone who traveled, been exposed to someone with flu-like symptoms, or is currently experiencing flu-like symptoms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    VISITOR/CONTRACTOR

    HEALTH DECLARATION
    FORM
    ORM
    Visitor/Contractor Name:

    Visitor/Contractor Company:

    Alfa Laval site address:

    Alfa Laval Contact whom visiting:

    HEALTH DECLARATION: By completing this form, I consent to Alfa Laval collecting, using and storing my
    personal information for the purpose of compliance with Alfa Laval and any Local, State or Federal Government’s
    or properly constituted authority’s, policies, procedures, directions, laws or regulations.

    INSTRUCTION TO SITE HOST:


    1. If ANY answer is YES – STOP. DO NOT PROCEED. Visitor/Contractor MUST be REFUSED access to site.
    2. If ALL answers are NO – CONTINUE. Visitor/Contractor is GRANTED access to site.

    QUESTIONS Circle Answer

    I am a confirmed case of COVID-19 (Coronavirus). YES NO

    In the last 14 days, I have had close contact with a


    YES NO
    confirmed case of COVID-19 (Coronavirus).

    In the last 14 days, I have returned from ANY


    YES NO
    overseas destinations.

    In the last 14 days, I have had close contact with


    someone who has returned from ANY overseas YES NO
    destinations in the last 14 days.

    In the last 14 days, I have had close contact with


    someone with flu-like symptoms (i.e. fever, cough, YES NO
    sore throat, runny nose, fatigue, difficulty breathing).
    I am suffering from symptoms flu-like symptoms (or
    in the last 48 hours), which may include:

     Fever
     Cough
     Sore-throat
     Running nose or Stuffy nose
    YES NO
     Headache, Aches and pains
     Fatigue
     Breathing difficulty

    OR any other symptoms (i.e. gastroenteritis related


    or similar) that may put our sugar/food products at
    risk.

    I declare that all the information given in this form is true and correct:

    Visitor/Contractor Name: Signature: Date:


    GRANTED / REFUSED
    Site Host Name: Signature:
    (circle answer)

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