COVID PANDEMIC VISITOR SCREENING TOOL 

 

Visitation Date:  ___________________________ 

 

Visitor #1 Name:  ______________________________________________________ 

 

Visitor #2 Name:  ______________________________________________________ 

 

Resident: ____________________________________________________________ 

 

Visitation Time:  ______________________________________ 

 

Visitor #1  

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Visitor #2 

 

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I have been educated with regards to safe visitation and agree to follow the directives as set forth in the Safe Visitation Guidelines Sheet. I have a negative Rapid Covid Test result from the past 24 hours, or a PCR Covid Test result from the past 48 hours with me.

 

Visitor #1 _______________________________________________________ 

 

Visitor #2 _______________________________________________________