About this template
A Health Declaration Form is an essential tool for organizations to maintain a safe environment by screening individuals for potential health risks. This template allows you to collect critical data regarding travel history, recent symptom onset, and potential exposure to infectious diseases. By standardizing this information, you can quickly assess the health status of employees, students, or event guests before they enter your premises.
Doc2Form makes it simple to deploy this screening tool. Whether you are managing a workplace, a school, or a public event, this form provides a clear, structured way to gather self-reported health data. It helps you stay informed and proactive in your safety protocols without the administrative burden of manual paper collection. Once respondents submit their information, all data is neatly organized in your Google Sheets, allowing for easy review and record-keeping.
Key features
- Captures travel history and symptom status in one flow.
- Standardizes health data collection for easy review.
- Mobile-friendly design for quick on-site completion.
- Easily export responses to Google Sheets for tracking.
- Clear, professional layout builds trust with respondents.
Use cases
- Daily employee health screening for office entry.
- Visitor and guest registration for corporate events.
- Student health monitoring for schools and universities.
- Pre-appointment screening for medical and dental offices.
What this form collects
- Full Name (Short answer)Please enter your full legal name.
- Contact Number (Short answer)Provide a phone number where we can reach you if necessary.
- Have you traveled internationally in the last 14 days? (Multiple choice)Please list the countries visited, if applicable.
- Travel Details (Paragraph)If you answered yes above, please specify the countries and dates of travel.
- Are you currently experiencing any of the following symptoms? (Checkboxes)Select all that apply: Fever, Cough, Shortness of breath, or Loss of taste/smell.
- Have you been in close contact with anyone diagnosed with an infectious disease in the last 14 days? (Multiple choice)Close contact is defined as being within 6 feet for more than 15 minutes.
- Additional Health Information (Paragraph)Please share any other information you believe is relevant to your health status.
- Declaration (Short answer)By signing below, I certify that the information provided is true and accurate to the best of my knowledge.
- Date of Submission (Date)Select today's date.
FAQ
What is the purpose of a health declaration form?
It is used to collect self-reported health information, such as recent symptoms or exposure, to help organizations maintain a safe environment for everyone on-site.
Who should use this form?
This form is ideal for HR managers, event planners, school administrators, and healthcare providers who need to screen visitors, staff, or attendees.
Can I customize the questions?
Yes. Once you convert this template to a Google Form, you can add, remove, or edit any questions to better suit your specific safety requirements.
How do I access the responses?
All submissions are automatically saved to your Google Form dashboard and can be linked directly to a Google Sheet for real-time data analysis.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.