Screening Form Template

Are you coming to visit?What's your full name?When will you be visiting?Have you traveled to a high-risk country in the last 14 days? Have you been in close contact with anyone who has traveled to a high-risk country within the last 14 days?Have you experienced any symptoms of COVID-19 in the last 14 days?Symptoms include fever, cough, shortness of breath and other respiratory problems.Have you been in contact with anyone in the last 14 days who is experiencing any of those symptoms?Have you had close contact with someone who tested positive for COVID-19 within the last 14 days?We might need to give you a quick call to clarify some things. Where can we reach you?And what's your email address?Thanks for your time!

Collect up to 3.5x more data with Typeform

Simplify health screenings

Got visitors coming to your office or organization? You want to make sure they're healthy and haven't been to any high-risk areas. This screening form will take them only a minute to fill in, so you'll get notified straight away if any risks crop up.

With Typeform, you can customize everything

Change text, colors, and even logos to match the look and feel of your brand. Then embed forms smoothly onto web and email.

Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.

Stay efficient by connecting forms to your workflow. Typeform integrates with 120+ tools including Slack, Zapier, and HubSpot.

Screening form FAQs:

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.