Attachment J8 - COVID19 Visitor Questionnaire.pdf
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- Solicitation number
- 75F40121R00014
About this file
This document contains a COVID-19 visitor screening questionnaire for Jefferson Labs, as well an opportunity for roof replacement services at multiple buildings on the National Center for Toxicological Research campus located in Jefferson, Arkansas.
The screening questionnaire requires all visitors to Jefferson Labs to complete the form within 24 hours prior to arrival, answering questions about recent COVID-19 symptoms or potential exposure. It must be emailed to specified FDA recipients for review. If any answers change or become positive before arrival, the Jefferson Labs Occupational Health Unit must be notified. All individuals entering the campus must wear face coverings.
The roof replacement opportunity is a solicitation issued by the FDA seeking services to repair or replace roofs on five buildings at its NCTR facility in Jefferson. Interested parties should review the attached solicitation for details on response due dates and requirements. The contracting agency is the Department of Health and Human Services Food and Drug Administration Office of Acquisition and Grant Services.
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Text version
Jefferson Labs COVID‐19 Screening Questionnaire (updated Feb 2021) Page 1 of 2
Jefferson Labs (JL) Visitors COVID-19 Screening Questionnaire
Instructions:
This screening questionnaire MUST BE completed by ALL visitors prior to their arrival on campus. It is the responsibility of the JL staff to have your visitor complete and return this questionnaire within 24 hours prior to their arrival on center
The questionnaire must be emailed to: NCTROHU@fda.hhs.gov and Elvin.Sprankle@fda.hhs.gov
The JL Occupational Health Unit must be notified at 870-543-7333 if the answers to the questions change prior to the visitor(s) arrival on campus
Per FDA guidelines, everyone entering the campus MUST wear a face covering.
Visitor and Sponsor Information:
Date:
Visitor’s Name and Company:
Name of the JL Sponsor/Escort and Division/Contractor:
Name of the Approving Official:
Has the JL staff received approval from the supervisor or Division Director for the visitor (Yes/No):
COVID-19 Screening Questionnaire
Please read each question carefully and choose YES or NO for each question.
YES
NO
Have you experienced any of the following symptoms in the past 48 hours:
Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea
Jefferson Labs COVID‐19 Screening Questionnaire (updated Feb 2021) Page 2 of 2
YES NO
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:
Anyone who is known to have COVID-19?
OR
Anyone who has symptoms consistent with COVID-19?
Are you in isolation or in quarantine because you may have been exposed to a person with COVID-19 or worried that you may be sick with
COVID-19?
Are you currently waiting on the results of a COVID-19 test?
Have you recently received a positive COVID-19 test result?
Did you answer NO to ALL questions?
Access to JLs APPROVED. The questionnaire responses must be emailed to NCTROHU@fda.hhs.gov
Did you answer YES to ANY question?
Access to JL NOT APPROVED
| Date: |
| Visitors Name and Company: |
| Name of the JL SponsorEscort and DivisionContractor: |
| Name of the Approving Official: |
| YesNo: |
| Did you answer NO to ALL questions: |
| Did you answer YES to ANY question: |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Check Box8: Off |
| Check Box9: Off |
| Check Box10: Off |
File details come from the government source that posted it. Updated .