COVID PANDEMIC VISITOR SCREENING TOOL 

 

Visitation Date:  ___________________________ 

 

Visitor #1 Name:  ______________________________________________________ 

 

Visitor #2 Name:  ______________________________________________________ 

 

Resident: ____________________________________________________________ 

 

Visitation Time:  ______________________________________ 

 

Visitor #1  

 

 

 

 

 

 

 

 

 

 

Visitor #2 

 

 

 

 

 

 

 

 

 

 

 

 

I have been educated with regards to safe visitation and agree to follow the directives as set forth in the Safe Visitation Guidelines Sheet 

 

Visitor #1 _______________________________________________________ 

 

Visitor #2 _______________________________________________________ 

Come and visit us at:

645 West Broadway,

Long Beach, NY 11561

Phone: 516-889-1100

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