SELF DECLARATION –VISITOR’S QUESTIONAIRE (COVID-19)

The safety of our employees, supplier partners, customers, families and visitors remain MSIL’s top
Priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally,
MSIL Medical and Vigilance teams are monitoring the situation closely and are periodically adapting
company guidance based on current recommendations from the Centers for Disease Control and
Prevention and the World Health Organization.
Only business critical visitors are permitted at any MSIL’s Premises at this time. To prevent the spread of
COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a
simple screening questionnaire. Your participation is important to help us take precautionary measures
to protect you and everyone in this building. Thank you for your time.

Visitor’s Name: Personal Contact Number:

Visitor’s Company/Organization: Name and Employee ID of Host:

Facility/Building Visiting: Visitor’s Age:

1 Do You Have any of the listed Cough Y N

symptoms? Difficulty in Breathing Y N
Respiratory Illness Y N
Sore Throat Y N
Running Nose Y N
Pneumonia Like Symptoms Y N
Fever (Temp> 98.6 F) Y N
Fatigue/Weakness Y N
Body Ache Y N
2 Have you had a, contact with Coronavirus positive case? Y N
3 Have you had contact with any staff treating Coronavirus positive case? Y N
4 Any travel to any other country in last two weeks? Y N
5 Date of 1st Dose of Vaccination
6 Date of 2nd Dose of Vaccination
7 Mode of Travel (Private/Bus/Train/Air)

If the answer is “yes” to any of the questions, access to the facility will be denied.

Signature: ____________________ Date: ____________________

**If answer to all the above is "NO, then visitor to carry this form at MSIL Reception***

PREVENT SPREAD OF CORONA VIRUS