National Institutes of Natural Sciences(National Institute for Basic Biology)(National Institute for Physiological Sciences)(Institute for Molecular Science)(Exploratory Research Center on Life and Living Systems)

Dear Visitor
Request for taking a screening questionnaire before entering the Okazaki 3 Institutes or
Exploratory Research Center on Life and Living Systems
For the safety and health of all employees, students and visitors of the Okazaki 3 Institutes andExploratory Research Center on Life and Living Systems, we are screening all visitor to decrease
the risk of COVID-19 transmission.
We appreciate your understanding as we ask you to comply with the following instructions.
-Check the other side of the paper and answer the following questions.
-Do not to forget to write your signature.
-After completing the screening form, get confirmation from your host researcher by getting
her/his signature.
-Keep this paper during your stay.
-Before leaving the site, submit this questionnaire to a security guard at the security service offices.
Personal information shall be used only for taking prevention measures against the novel
coronavirus disease, identifying a cluster of COVID-19 when it happens, and decreasing the risk ofinfectious disease transmission. We shall destroy this questionnaire within one month, after
keeping it at Okazaki Administration Center.

Your participation is important to assist us in taking precautionary measures to protect youand others in our facilities. Thank you.

Visitor Screening Questionnaire
If you answer “YES” to any of the bellow, you will not be permitted entry to the site or touse the facilities.
□ I do not apply to the following symptoms or statements.
1. Do any of the following symptoms currently relevant to you?
1-① Fever (temperature of 37.5°C or higher, or more than 1°C higher than your normal temperature)
1-② Shortness of breath(difficulty breathing)
1-③ Loss of smell and taste
2. Please review the following statements and select all statements that apply to you:
2-① You are aware that you have been exposed to someone who has been diagnosed
with the Coronavirus (COVID-19) within the last 14 days.
2-② You or your family member has experienced fever, shortness of breath(difficultybreathing), or a strong feeling of weariness(fatigue) within the last 14 days.

Period of Stay:~□ I do hereby agree that the following:①I will take the following thorough prevention measures for the spread of the novel coronavirus:-Covering my mouth and nose with a mask
-Washing my hands often with soap and water-Taking my temperature and monitoring my health-Staying at home if I am sick
- Keeping enough distance from others② If there has been a confirmed case of COVID-19 on the site, NINS*1 may use and disclose any
information related to me only to relevant administrative organs for the purpose of finding clustersof infections.

*1National Institutes of Natural Sciences

Date:
Visitor Card Number*2(Signature)
Institution*3:

2* Please write your visitor card number
before you leave.

Phone Number*3:
Email Addresses*3:*3If you have already submitted any information forms concerning health condition survey to your host researcher, the above
three questions are optional.

(Host Researcher’s signature*4)*4If you visit Institute for Molecular Science(IMS) to conduct your research project, you do not need to get your hostresearcher’s signature. Please follow the rules made by IMS.

Thank you for assisting us in these measures to keep our employees and visitors safe.