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Visitor Questionnaire

Page Updated: April 27, 2022

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Prior to visiting a CoorsTek facility, we request that you complete this questionnaire and provide your responses to your CoorsTek contact.

1. Are you fully vaccinated? Yes   No

 

If you answer yes to any of the questions below, you are requested to reschedule your visit, provide a remote meeting option or send an alternative company representative

2. Have you traveled outside this country in the past 14 days?  Yes   No

3. Do you know if you have been in close contact with anyone diagnosed or presumed positive with COVID-19 in the past 14 days? Yes   No

- If yes, and you are fully vaccinated, you may proceed with your visit; however, you are required to wear a mask at all times.

4. Do you currently have a fever or any signs of illness? Yes    No
    Check those that apply:

- Visitors who answer yes to one of these symptoms should reschedule, provide a remote meeting option or send an alternative company representative:

o Fever □

o Fatigue/Weakness □

o Dry cough □

o Shortness of breath or difficulty breathing □

- Visitors who answer yes to 2 or more of these symptoms should reschedule, provide a remote meeting option or send an alternative company representative.

o Chills or shaking with chills □

o Muscle pain or body aches □

o Headache □

o Sore throat □

o Loss of taste or smell □

o Congestion or runny nose □

o Nausea or vomiting □

o Diarrhea □

 

Date: ______________________________________________

Visitor Name: _______________________________________

Company: __________________________________________

CoorsTek Contact: ___________________________________

CoorsTek Facility: ____________________________________

 


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