COVID-19 Screening for Visitors and Contractors

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our employees, and visitors, we are conducting a simple screening questionnaire. Your participation is important to help everyone take precautionary measures to protect yourself and others around you.
This questionnaire must be filled out for all visitors coming onto the property.
Today's Date*
Name (Print Clearly)*
Phone Number (Personal and/or Company)*
Company/Organization:*
Spectrum Contact (if known):
Email (in lieu of signature)*
Branch being visited:*
Branch Visiting
Have you returned from one of the countries listed in the Level 3 CDC Travel Health Notices in the last 14 days?
*
- YES
- NO
Have you had close contact or cared for someone diagnosed with, or suspected to have, COVID-19 within the last 14 days?
*
- YES
- NO
Have you been in close contact with anyone who has travelled to one of the countries listed in the Level 3 CDC Travel Health Notices within the last 14 days?
*
- YES
- NO
Have you experienced any cold or flu-like symptoms in the last 14 days? (to include one or several of the following: fever, cough shortness of breath)
*
- YES
- NO
If the answer is yes to any of the above questions, access to the branch will be denied.

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