Fire-Rite/IMS Visitor Questionnaire
Fire-Rite/IMS strives to provide a safe working environment for all employees, customers, and visitors. As the Coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, Fire-Rite is monitoring the situation closely based on current recommendations from the Center for Disease Control (CDC).

To reduce the potential risk of exposure to our employees and visitors to the seasonal influenza (flu) & COVID-19, we are conducting a screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this facility.

Access to the facility will be determined on a case by case basis. In the event your access is denied, we will arrange an alternative method to address your business need.

We sincerely appreciate your cooperation!
Name *
Your answer
Visitor's Company Name
Your answer
Phone Number (work/mobile) *
Your answer
Name of Firerite/IMS Employee Host *
Your answer
Location *
Have you visited any foreign country within the last 14 days? *We will follow the most up-to-date CDC guidelines in deciding if an individual is approved to enter. *
If you have visited a foreign country within the last 14 days, what country/countries?
Your answer
Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, or difficulty breathing)? *
If you have experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, or difficulty breathing, please specify the symptoms and timing.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy