Atch 4 - YYYYMMDD_CovidQuestionnaire (LAST NAME).pdf

Date Updated: 08/25/2020

AEDC White Oak Tunnel 9 COVID-19 Visitor Questionnaire

Due to the ongoing COVID-19 pandemic, all visitors to Tunnel 9 must fill out and return this questionnaire to the AEDC Tunnel 9 staff member sponsoring their visit before gaining base access. Base access can be denied based on the response to this questionnaire. During the course of the visit, all visitors must alert the Tunnel 9 staff member sponsoring their visit if any of the answers to this questionnaire change.

Additionally, all visitors must follow all health and safety protocols at AEDC Tunnel 9, including:

• Wearing a face covering at all times (face coverings with valves are NOT allowed)

• Maintaining appropriate physical distancing of 6ft. or more from other staff members/visitors

• Observing maximum room occupancy as posted

• Washing/sanitizing hands often (hand sanitizer provided in high traffic areas)

• Observing all local and state COVID-19 regulations

Please answer the following questions and return form to the AEDC Tunnel 9 staff member sponsoring your visit prior to attempting to access the facility.

In the past 14 days have you:

1) Had any of the following COVID-19 symptoms?

Yes No

If yes, please explain:

2) Traveled outside of the continental United States?

Yes No

If yes, please explain:

3) Tested positive or been in close contact with someone who has tested positive for

COVID-19?

Yes No

If yes, please explain:

Visitor Name: Current Date:

T9 Sponsor Name: Initial Visit Date:

• Fever and/or chills

• Cough

• Fatigue

• Muscle or body aches

• Shortness of Breath or difficulty breathing

• Sore Throat

• Headaches

• Nausea/Vomiting

• New loss of Taste/Smell

• Congestion or runny nose

• Diarrhea