Harbar Visitors - COVID 19 Self screen
We are Harbar are committed for the health of our team members and our community, therefore, before visit our locations we will ask you to complete this form prior your arrival. One form for each individual.

If you encounter problems loading or filling out this electronically please notify your Harbar contact so he/she provides you a paper copy
Sign in to Google to save your progress. Learn more
Name *
Company *
Phone # *
1.- I self-certify I have no symptoms (100.3°F temp., cough, trouble breathing, diarrhea & lost of taste and smell w/in 24 hrs.) *
Required
3.- I self-certify that I have had no close contact with a diagnosed COVID-19 individual (Outside Harbar and/or with no mask and more than 15min) *
Required
4.- I self-certify that I have not been told to self-isolate or quarantine by LBOH or MD *
Required
5.- I understand and agree, I need to keep social distance (6ft) in all areas *
Required
6.- Do you have a face mask? *Note: Face mask is Mandatory to wear at our locations *
Required
9.- Who will you be meeting at Harbar *
Reason for your visit
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Harbar LLC. Report Abuse