COVID-19 Visitor Questionnaire – Strategic Analysis, Inc. - COVID-19 Visitor Questionnaire

The safety of our employees, customers, suppliers, families, and visitors remains Strategic Analysis’ overriding priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, SA’s management team is continuously monitoring the situation closely and periodically updating company guidance based on current recommendations from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Currently, access to SA’s facility is limited to employees and essential business visitors.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is required to help us take precautionary measures to protect you and everyone in the headquarters office spaces. Thank you for your time.

Visitor Full Name *

Personal Phone Number (mobile/home) *

Company/Organization *

Date of Visit/Meeting *

Name of SA Meeting Host *

Have you ever tested positive for SARS-CoV-2? *

Yes

Please provide the date a medical professional cleared you to return to a workplace and attach the provided documentation: *

Are you currently waiting on the results of a COVID-19 test? *

Yes

Have you experienced any cold or flu-like symptoms in the last 14 days?*

Fever over 100.4
Cough
Chills
Shortness of Breath or Difficulty Breathing

Fatigue
Muscle or body aches
Headache
New loss of taste or smell

Sore Throat
Congestion / Runny Nose
Nausea or Vomiting
Diarrhea

Yes

Within the last 14 days, have you had any close contact with someone who has shown COVID-19 symptoms or has tested positive for SARS-CoV-2? *

Yes

If the answer is “yes” to any of the questions, access to the facility will be denied.

By initialing and dating below, I confirm that I have honestly completed this form and if any information arises that would change my answers that I will contact SA and notify them of this change in response so, if applicable, SA can notify other persons that may have been in contact with me of their possible exposure. SA will keep your name anonymous unless required by law to report your name and only to the required organization.

All visitors agree to contact SA Facilities/Security if they find out that any of the answers should have been different based on information received after the visit (i.e., they find out someone they were had contact with prior to visiting SA has found out they tested positive for COVID-19).

Visitor Initials & Date *

Note: if you plan to be onsite for consecutive days, please immediately advise your SA host if any of your responses change. The information collected on this form will be used to determine your access right to SA facilities.