04C 1300964413 Synopsis Attachment 02 NSA Panama City - NSWC PCD Initital Visitor Pre-Screening Forms_Updated.pdf

NSA Panama City/NSWC Panama City Division

VISITOR / VISITING GROUP NOTIFICATION FORM

DATE: ___________________ Team/ Group: _________________________

FIRST NAME LAST NAME Visiting From (City/ST)

This page only need to be provide once, at the time of notification of a visitor or group of visitor that is coordinating a visit and COVID-19 Screening requirements for base access. This form only declares the personnel that are in a group visiting the installation.

Medical Questionnaire and Temperature Screening

DATE: ___________________ Person Submitting Screening: ___________________________

Team/ Group: _________________________ # of Members______

This page is requested to be provided daily, for 14 days prior to arrival to the NSA PC Installation. If 14 days prior is not possible due short scheduling, please commence screening and reporting as soon as possible and continue while operating on the installation until 14 days has been completed or your visit is completed (whichever is shorter). If your visit extends beyond the 14 NSA PC Screening and reporting requirements, you/ your team will follow any screening requirements that are in place by the command or office that you are visiting or working with, through the end of the visit. The number of personnel on the first page should be screened daily and reported for on this page, for the 14 day duration.

To ensure HIPAA, PII, and DON HRPP compliance, the team lead will ensure that names are not associated with an individual’s COVID-19 screening data.

Please select yes or no to answer questions corresponding to each individual screened.

Te st

P er so nn el

In past 24 hours has individual: In past 14 days has individual: COVID-19 Positive History

Does individual have a current, measured temperature >

100OF?

Exhibited fever, cough, sore throat, shortness of breath, loss of smell, or loss of taste?

Travelled internationally?

Had DIRECT contact, with anyone tested positive for COVID-19?

i.e., Been WITHIN 6 feet, for a duration GREATER THAN than 15 minutes and/or WITH or WITHOUT face covering.

Have you been tested for

COVID-19?

Have you tested positive for COVID-19 in the last 14 days?

1 YES NO YES NO YES NO YES NO YES NO YES NO

2 YES NO YES NO YES NO YES NO YES NO YES NO

3 YES NO YES NO YES NO YES NO YES NO YES NO

4 YES NO YES NO YES NO YES NO YES NO YES NO

5 YES NO YES NO YES NO YES NO YES NO YES NO

6 YES NO YES NO YES NO YES NO YES NO YES NO

7 YES NO YES NO YES NO YES NO YES NO YES NO

8 YES NO YES NO YES NO YES NO YES NO YES NO

9 YES NO YES NO YES NO YES NO YES NO YES NO

10 YES NO YES NO YES NO YES NO YES NO YES NO

11 YES NO YES NO YES NO YES NO YES NO YES NO

12 YES NO YES NO YES NO YES NO YES NO YES NO

13 YES NO YES NO YES NO YES NO YES NO YES NO

14 YES NO YES NO YES NO YES NO YES NO YES NO

15 YES NO YES NO YES NO YES NO YES NO YES NO

16 YES NO YES NO YES NO YES NO YES NO YES NO

17 YES NO YES NO YES NO YES NO YES NO YES NO

18 YES NO YES NO YES NO YES NO YES NO YES NO

19 YES NO YES NO YES NO YES NO YES NO YES NO

20 YES NO YES NO YES NO YES NO YES NO YES NO

My signature below hereby certifies that I have screened all test personnel at the test site for which I am responsible. I further certify that I ensured anyone opting out of the screening or who could not meet the

COVID-19 criteria within 30 minutes of an initial screening will not visit the installation or associated sites.

Team Lead (or Designee) Printed Name Signature