Visitor & Contractor questionnaire
In keeping with public health compliance during COVID-19, we require visitors and contractors entering our site to complete the following COVID Questionnaire. This must be completed and submitted prior to any onsite visit. The company is collecting this data for the purposes of maintaining safety within the workplace in light of the COVID-19 pandemic. The legal basis for collecting this data is based on vital interests and maintaining occupational health and will be held securely in line with GDPR guidelines. PRIVACY OF INFORMATION All information submitted is confidential and will be reviewed and maintained as confidential. If a visitor/contractor replies with “Yes” to Question 1 to 6, the visit must be rescheduled to allow for the appropriate time to pass and are advised to seek professional medical help/assistance. If a visitor/contractor replies with “Yes” to Question 7, we may reach out to seek further information to allow scheduled visit to proceed. All visitors and contractors must sign in at the computer kiosks located at the front desks at the commencement of visit and are required to complete temperature testing. For further information please reach out to your Surmodics Contact.
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 10 days?
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 10 days?
Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 10 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)?
Have you been advised by a doctor to isolate or restrict movements at this time?
Are there are any other circumstances relating to COVID-19, not included in the form, which may need to be disclosed to allow safe site access.
I declare that the information given above is true and complete.