Visitor Screening - COVID-19 Health Status Declaration Template

Updated: 2 days ago


Mindfulness and self-declaration are incredibly important to mitigating the spread of viruses in an age of the modern global economy. In an effort to keep our client’s workplace safe, iVenuto ZAP IN has created an access policy based on the latest recommendations from the Center for Disease control (CDC https://www.cdc.gov/coronavirus/2019-ncov/faq.html) and the US government’s task force (coronavirus.gov https://www.cdc.gov/coronavirus/2019-ncov/index.html). We encourage alerting all visitor traffic to be more mindful and aware of best practices. Use the Visitor Agreement feature to present this alert and self-declaration. Or add it to your current access policy.

Let’s keep our workplaces free from these viral threats!


Clip and Paste the following workplace access policy in Visitor Agreement feature:


Covid-19 Health Screening

Personal Declaration of Health & Travel Status

Stay Safe – Save Lives!


Within the past 72 hours, I have not experienced and am free from any of these symptoms:

• Fever > 100.4F (38C) / Chills

• Shortness of Breath / Difficulty breathing

• Headache

• Cough / Sore Throat

• New loss of Taste or Smell

• Flu like symptoms of Fatigue, Muscle or Body Aches

• Congestion or Runny Nose

• Nausea or Vomiting / Diarrhea

If you have experienced any of these symptoms as a result of seasonal allergies, or a pre-diagnosed / treated medical condition, then please advise your contact / host immediately.

Within the last 14 days, I have not travelled internationally or participated in an activity (outing, cruise, gathering, event) with:

· a reported outbreak

· more than 10 people in attendance

· insufficient access to face-masks or hand-sanitizer

· not adhering to physical distancing of 6 feet or more


Within the last 14 days, neither I, or anyone in my immediate household has been:

· required to self-quarantine.

· contacted by Public Health authorities regarding possible exposure to Covid-19.


Within the last 14 days, I have not:

· tested positive for COVID-19

· been within 6 feet of a symptomatic or confirmed COVID-19 individual

· visited a Senior Citizen’s Nursing, Retirement or Assisted Living facility

· visited a medical facility caring for / treating Covid-19 patients


Help us stay safe – do not enter these premises if ANY of the above statements are not accurate.

Help us save lives – phone or email your host /contact now if you have any questions or need clarification.


I, {firstname} {lastname}, hereby state that the health and travel statements contained herein are true and accurate.


(Make sure your Signature Capture feature is enabled)


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