Visitor Health Questionnaire

For visitors entering food storage and handling areas.

Doc No: RSAL-IMS-HSSEQ-F-51
Revision Date: 01.07.2021

Visitor Details

Name*

Organisation*

Date*

Purpose of Visit*

Time*

Health Questions — please tick the appropriate box

Have you ever suffered with

#	Question	Yes	No
1	Enteric fever (typhoid or paratyphoid)?	Yes	No
2	During the last 48 hrs, have you suffered from nausea, vomiting or diarrhoea or taken antidiarrhoeal drugs?	Yes	No
3	A food allergy (eg. Nuts)	Yes	No
4	Hepatitis or jaundice?	Yes	No

Are you currently suffering from

#	Question	Yes	No
5	Productive cough and/or sneezing	Yes	No
6	Acne, boils, septic cuts or sores?	Yes	No
7	Discharge from eye, ear, gums or mouth?	Yes	No
8	Scaling condition of the hands, forearms or face?	Yes	No
9	Are you currently suffering from, or have you suffered within the last 7 days from hepatitis or jaundice?	Yes	No
10	Have you been outside the UAE within the last 3 months — please state where	Yes	No
11	Have you suffered from any illness since?	Yes	No

Note

1. If you answered Yes to any of the above questions, the Person-In-Charge will determine your suitability to enter food storage and handling areas.

2. Please do not handle any food products or surfaces where food is stored or transferred, unless given permission to do so to avoid any type of cross contamination.

Terms and Conditions

I declare that the information provided in this questionnaire is accurate to the best of my knowledge.

I agree to comply with food safety regulations and will not handle food products without permission from the Person-In-Charge.

I have read and agree to the Terms and Conditions stated above. *

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