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The safety of our employees, customers, suppliers, families and visitors remains Cyrus Persian Academy’s overriding priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally,
Cyrus Persian Academy is monitoring the situation closely and will periodically update company guidance based on current recommendations from the Center for Disease Control and the World Health Organization. Only business critical visitors are permitted at our facility at this time.
To prevent the spread of COVID-19 and reduce the potential risk of exposure to our employees 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 Phone Number (mobile/home): Visitor’s Company / Organization:
Purpose of visit: Self-Declaration by Visitor

Have you returned from any of the countries listed on the CDC Website within the last 14 days? Yes □ No □

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
Yes □ No □

Have you been in close contact with anyone who has traveled within the last 14 days to one of the countries listed on the CDC Website?
Yes □ No □

Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing?
Yes □ No □
If the answer is “yes” to any of the questions, access to the facility will be denied.
Signature (visitor): Date:
Signature (host): Date:

Note: If you plan to be onsite for consecutive days, please immediately advise your Made to Measure host if any of your responses change. The information collected on this form will be used to determine your access rights to our facility.

Access to facility (circle one): Approved Denied

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