Visitor Screening

New Covid-19 Screening Form

Title *
Date of Screening
Province *
LB Office *
Date of Visit *
Visitor Name *
Visitor Surname *
Telephone Number *
Cellphone Number *
Email Address *
Organization *
Date of Birth *	Format: DD/MM/YYYY
Have you recently travelled out of the province/country? *
If yes, please state province/country
Have you been in contact with someone recently diagnosed with COVID-19? *
Transport Used to Get to the Office? *
Symptoms
Temperature
Visitor Personal Acknowledgement	The undersigned acknowledges that Land Bank can conduct a temperature screening test before allowing access to the Land Bank premises. The undersigned understands and agrees that, should the temperature reading present any result which the Land Bank requires that it refer me for further assessment, I shall comply with such.
Send Referral Letter?
Security Personnel
Attachments