Visitor – YAPP USA Automotive Systems, Inc.

YAPP Facility Location: *

Visitor Name: *

First

Last

Visitor Phone Number: *

Visitor E-mail: *

Visitor Company: *

YAPP Host: *

Have you returned from any of the listed countries below: *

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *

Yes
No

Have you experienced any cold or flu-like symptoms? Do you currently have fever, cough, difficulty breathing, chills, repeated shaking with chill, muscle pain, headache, sore throat, new loss of taste or smell, nausea, vomiting, or diarrhea ?

Yes
No

Have you been tested for the COVID virus in the last 14 days? *

Yes
No

If Yes, have you received a positive result or still pending the results? *

Yes
No

Visitor signature *

Date *

YAPP Visitor Health Screening Questionnaire