COVID-19 Screening Questionnaire – Employees & Visitors

Type(Required)

Employee

Contractor

Visitor

Have you visited Hydro Tech’s facility before?(Required)

Yes

Current Temperature(Required)

Company

Name(Required)

First Last

Email(Required)

Gender(Required)

DOB(Required)

Telephone(Required)

Address(Required)

Street Address City Country

Department/Person visiting at HTL(Required)

Location visiting at HTL(Required)

Purpose of Visit(Required)

Have you or any other member of your household had any direct contact with a person who was diagnosed with 2019 Novel Coronavirus (COVID-19) within the past 14 days?(Required)

Yes

Has any member of your household travelled abroad within the past 14 days OR have you been in contact with anyone who has travelled within the past 14 days?(Required)

Yes

Please supply details of travel activity

Do you currently have any of the following symptoms? (Tick ONLY if answer is YES)

Fever

Cough

Runny nose

Sore throat

Headaches

Shortness of breath

General feeling of being unwell

If general feeling of being unwell was selected, please provide further details

By selecting Yes in the Consent area below I declare that the responses contained herein are true and correct and agree to my immediate removal from any of Hydro Tech’s or its client’s sites should any of my responses herein be found to be untrue and incorrect. I also hereby consent Hydro Tech collecting, processing and storing any of my personal and sensitive data (as defined in the Data Protection Act 2011) provided in this form, for the purpose of determining my level of exposure to 2019 Novel Coronavirus and any further action required to be taken.

I Consent(Required)

Yes

HTL-HR-F-022 March 18th 2020: Rev 4