Visitor questionnaire

Date

Time

Company name

Visitor name

Contact person Beutlhauser

Regarding / Reason for meeting

Are you tested, vaccinated or recovered ? Are you tested, vaccinated or recovered ? I am considered fully vaccinated against COVID-19. I have a current negative antigen test or PCR test (48h). I am considered recovered.

Have you visited any level 2 or 3 countries in the past 14 days (see CDC Travel Health Notices)? Have you visited any level 2 or 3 countries in the past 14 days (see CDC Travel Health Notices)? No Yes

Have you been in any of the above countries and have you been in close proximity to people showing signs of illness (coughing, sneezing, fever, etc.)? Have you been in any of the above countries and have you been in close proximity to people showing signs of illness (coughing, sneezing, fever, etc.)? No Yes

Do you know if you have been involved with someone who has been diagnosed with COVID-19? Do you know if you have been involved with someone who has been diagnosed with COVID-19? No Yes

Do you currently have a fever or signs of illness (cough, cold, etc.)? Do you currently have a fever or signs of illness (cough, cold, etc.)? No Yes

Privacy Privacy I have read the data protection declaration (https://beutlhauser.com/datenschutz/) and agree that the data I have provided may be collected and stored electronically. All data will be used strictly for the intended purpose in accordance with the privacy policy.