Visitors

Name:

Date of Birth

Company Name

City

Country from which you travel

Which countries had you visited in the last 15 days?

Date of visit to Avery Tijuana

Name your sponsor or contact at Avery Plant:

Sponsor email:

Reason for Visit:

Do you have/had a family member with flu symptoms, cough, temperature, hospitalized, suspicious or diagnosed with COVID-19, in the last 15 days?

Yes

No

If your answer is yes, please describe

Have you had contact with someone diagnosed with COVID-19 and/or hospitalized in the last 7 days?

Yes

No

Have you been diagnosed with COVID-19?

Yes

No

At this time, do you have any of the symptoms Described below, please mark:

Free Text

You may be required to take a medical exam at Avery. Your access to the facility could be denied if there is an indication of contagious and/or not complying with sanitary and health requirements to keep our Plant COVID-19 Free.

have you been vaccinated against covid 19?

Yes

No

If Yes, which one?

Date of vaccination

Opt-In

I HEREBY CERTIFY THAT ALL THE ABOVE INFORMATION IS TRUE

Contact Us

Contacto