COVID-19 Self-Certification Form.pdf
PDF 183 KB Posted
- Solicitation number
- 12444822Q0025
- Issued by
-
Department of Agriculture Forest Service
About this file
This document contains a COVID-19 self-certification form and details of a federal contract opportunity for custodial services. The self-certification form requires vendors to attest that they are not exhibiting COVID-19 symptoms or have been exposed to the virus, and will comply with safety protocols including use of PPE and social distancing.
The federal contract opportunity is soliciting offers for custodial services at the Forest Products Laboratory in Madison, Wisconsin. The services include providing all personnel, materials, equipment and supplies necessary to perform custodial work according to the performance work statement. The period of performance is from September 1, 2022 through August 31, 2027. Offers are due no later than July 25, 2022. The solicitation is being conducted by the Department of Agriculture Forest Service.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| SCHEDULE OF ITEMS -FPL Janitorial.xlsx | XLSX spreadsheet | |
| Sol_12444822Q0025_Amd_0001.pdf | ||
| Sol_12444822Q0025_Amd_0001_Editable.pdf | ||
| 12444822Q0025_01.pdf | ||
| 12444822Q0025.pdf |
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Text version
COVID-19 Self-Certification Form
Vendor Name:_______________________________________________________________
Vendor Contact Information: ____________________________________________________
Vendor Emergency Contact Information: ___________________________________________
Prior to starting this Site Visit I, ______________________________, certify and confirm that the following statements are true:
• I am not exhibiting any of the following symptoms associated with
COVID-19:
o Fever of 100.3°F or higher o Cough o Shortness of breath or difficulty breathing;
• Two or more of these symptoms not due to a pre-existing condition:
o Fever o Chills o Repeated shaking with chills o Muscle pain o Headache o Sore throat o Nausea or vomiting o New loss of taste or smell
• I have not been in close contact with anyone within the last 14 days who has been quarantined or isolated due to COVID-19.
• I have not been advised by any medical provider or health authority that I may have been exposed to COVID-19.
• I have not traveled out of the country in the past 30 days or been in close contact with anyone who has traveled out of the country in the past 30 days.
• Have not been asked to self-isolate or quarantine by their doctor or a public health official.
• All Vendors are required to use appropriate personal protection equipment, including masks, and must comply with all local and state ordinances regarding social distancing and restrictions on gatherings.
Vendor Name and Signature Date llfll
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