Health Screening for Hotel Guests
Dear Sir / Madam:

To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in our hotel.

Please fill-up the form below. Thank you for your time.
Email address *
Guest name: *
Passport Number
Phone number
Preferred contact method
Have you been in contact with a confirmed COVID-19 patient in the past 14 days?
Clear selection
Have you been to Mainland China or affected countries or area(s) in the past 14 days?
Clear selection
If yes, please indicate the affected country(s) or area(s)
Do you have the following symptoms:
Yes
No
Fever
Dry Cough
Sore Throat
Shortness of Breath
Clear selection
I hereby certify that the information given are true, correct and complete.
Date
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy