Ciena Visitor Health Screening Questionnaire

The safety of our employees, customers, families, and visitors remains Ciena's overriding priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to globally evolve, Ciena Real Estate and Security are monitoring the situation closely and will periodically update company guidance based on current recommendations from the U.S. Center for Disease Control and the World Health Organization.

To help prevent the spread of COVID-19 and reduce the potential risk of exposure to our employees and visitors, please complete this screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building or event. Thank you for your time.

Visitor Name:

Visitor Phone Number:

Visitor Company/Organization:

Ciena Host:

Facility Name:

By completing and signing this document you agree that:

1. You are fully vaccinated or have a negative result from a COVID PCR test taken within the last 72 hours.

2. You have not had close contact with or cared for someone with a confirmed or probable case of COVID-19 in the last 10 days.

3. You have not experienced any cold or flu-like symptoms in the last 10 days? This includes fever, cough, sore throat, respiratory illness or difficulty breathing.

Visitor Signature:________________________________ Date:_______________________

If you do not meet any of the above statements, access to the Ciena facility will be denied. If your visit spans multiple days, please immediately advise your Ciena host if any of the above changes. The information on this form will be used solely to determine your access rights to Ciena facilities. For more information, see Ciena’s privacy statement at

“By completing, signing and submitting this form, you consent to Ciena processing the personal data you have provided for the specific purpose of identifying, assessing and managing risks related to the COVID-19 virus outbreak as well as determining and controlling access to Ciena company premises for the purposes of public health, safety and security (“the Purpose”). The personal data you provide will be held for sixty (60) days or until such time as the COVID-19 virus outbreak has resolved, whichever is the later in time. Access to such personal data will be strictly limited to those Ciena personnel (including external third-party contractors who provide security and facilities services to Ciena) required to carry out the Purpose. Ciena will take appropriate technical, administrative, organizational and security measures to protect the personal data you provide.”

Facility Access: Approved Denied (Circle One)

Reviewer Signature:_______________________________ Date:_______________________