CODE: NFPC/IMS/FO11

INTEGRATED MANAGEMENT SYSTEM ISSUE DATE: Mar 2021

Infectious Diseases Health ISSUE NO: 4
Questionnaire PAGE: 1/2

This form must be completed by all visitors to NFPC premises and by all employees
entering NFPC premises for the first time after travelling from overseas.
YOU MUST ANSWER ALL QUESTIONS
Date:

Name:

Company:

Signature:

Have you travelled overseas during the last 10 days, including airport and port
transits? If so, where (most recent first)?
Country 2
YES / NO
Country 1 Country 3

Have you had any of the following in the last 48 hours, including today
YES NO
Fever, chills or muscle weakness?
Unusual cough?
Vomiting / diarrhoea / nausea / stomach pain?
Skin discoloration or rash?

During the last 10 days, have you been in contact with anybody who you know to have
been suffering from any of the following?
YES NO
Coronavirus (MERS, SARS, COVID-19)
Fever, chills or muscle weakness
Unusual cough
Vomiting / diarrhoea / nausea / stomach pain / skin discoloration or rash
Typhoid fever
Measles
Influenza

When completed, please return this document to the person you are intending to meet
at NFPC. Thank-you.
 CODE: NFPC/IMS/FO11

INTEGRATED MANAGEMENT SYSTEM ISSUE DATE: Mar 2021

Infectious Diseases Health ISSUE NO: 4
Questionnaire PAGE: 2/2

For internal NFPC use only.

Instructions to the host (for visitors) or supervisor (for employees returning to work):
1. Please forward this form to your site QC Manager, or to the Director QHSE R&D.
2. The Site QC Manager or Director QHSE R&D will review the form and issue approval
for the visitor/employee to come on-site.
3. If the Site QC Manager or Director QHSE R&D considers that there is a significant risk
to the health of NFPC employees by allowing the visitor/employee to come on site, the
request will be rejected.
For visitors who are rejected, please inform the visitor and ask them to make alternative
arrangements (eg by video conferencing, telephone discussion or by re-scheduling their
visit).
For employees who are rejected, please instruct the employee to remain in self-isolation
until they can answer NO to all the questions. If they have a fever, please instruct them
to see a doctor or health provider before returning to work.

Instructions to the Site QC Manager / Director QHSE R&D

1. If the visitor / employee has answered YES to one or more of the health questions, they
may not enter NFPC premises.
2. If the visitor/employee answers has travelled overseas to a high-risk country (based on
the most recent WHO Epidemiological Report) in the last 10 days they may not enter
NFPC premises.

Approval to enter site

Date:

Position: Site QC Manager / Director QHSE R&D

Name:

Signature: