Visitor Travel and Health Declaration

Coronavirus (COVID-19) Prevention

HORIBA Instruments Incorporated is committed to protecting the health of our employees, customers, business partners, other visitors to our site, and our community. Towards that end, please answer the simple questions below in support of our precautionary measures to protect against the spread of CORVID-19. We recognize that it is also flu and cold season, and symptoms for these illnesses can be similar to the Coronavirus. In an abundance of caution, we ask that anyone with symptoms seek medical attention and refrain from entering our site.

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* 1. Name

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* 2. Email Address

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* 3. Company

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* 4. Who are you visiting?

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* 5. Which location are you visiting?

Austin, TX

Portland, OR

Reno, NV

Sunnyvale, CA

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* 6. When do you plan to visit HORIBA?

Date / Time

Date

Time

AM/PM

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* 7. Have you traveled to a Warning Level 3 region as determined by the CDC (CDC Travel ) within the last 14 days?

Yes

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* 8. Have you exhibited any Symptoms of COVID-19 in the last 14 days? These most commonly fever, cough and/or shortness of breath? Also includes chills, muscle pain, headache, sore throat, and new loss of smell and taste.

Yes

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* 9. In the last 14 days have you had contact with someone with a confirmed diagnosis of COVID-19; been under investigation for COVID-19; or ill with a respiratory illness?

Yes

Note: If you plan to be onsite for consecutive days, please immediately advise your HORIBA host if any of your responses change, The information collected on this form will by used to determine your access rights to HORIBA facilities. We will be in touch shortly to confirm your visit.