PROJECT NAME COMPANY LOGO

VISITOR HEALTH DECLARATION FORM

As a precautionary measure to support efforts to limit the spread of Coronavirus (COVID-19)

and ensure the safety and wellbeing of our employees and operations, you are requested to fill
in the below details.

Visitor Information:
Visitor Name: Company:
Visitor Address: Date:
Contact No: Time In:
Nationality: Duration of visit:

Purpose of visit:

Visitee Information:
Name:
Company:
Contact:
E-mail:
Multiple Visitees: Yes No
Schedule Visit: Yes No

Declaration by Visitor:
If you have below symptoms, Please tick the relevant.
i. Fever ii.Runny nose iii.Headache iv.Body aches
v. Shortness of breath vi. Sore throat vii.Dry cough viii.Tiredness
I hereby declare that I have not travelled outside of the United Arab Emirates in the past 14
calendar days.
I hereby declare that I have travelled to the outside of the United Arab Emirates in the past
14 calendar days. The full list of all countries/regions that I visited (including those which
were transited through) is as follows:
List ALL countries/regions visited below:

I hereby declare that I did not experience any *symptoms Yes No

of COVID-19 virus in last 14 days.
I confirm that the information given in this Visitor Travel History Declaration is true, complete and accurate.

Visitor Signature:

Received By (Name):

*Common symptoms- respiratory symptoms, fever, cough, shortness of breath, sore throat and breathing difficulties.