Attachment 11 - CDRL A003 - Travel Quarantine Isolation-Tracker.pdf

DD FORM 1423-1, FEB 2001

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

DLA Employee

Submitting Organization: Submitting Organization POC:

Date Submitted: MMM-

Employee Information Quarantine/Isolation

Tracking ID (create your own tracking numbering system) MSC/J-D Code (leave blank) Contractors (CTR) Duty Location (self explanatory) CONUS/OCONUS (self explanatory) Status (quarantine or self isolation) Current Location (duty location) Home/Facility (where employee is quarantined) Start Date of Quarantine End Date of Quarantine is TBD (fill this date in when employee has recovered and add to comment section) Work Status (Telework, Leave, Workplace, etc) Last Day Physically Present at work CAT A (place an X if applicable) Date Added as CAT A Detailed Impact to Mission (closures, rescheduled appointments, delays, etc.) Detailed Impact to Workforce (quarantines due to exposure, etc.) CAT B (place an X if applicable) CAT C (place an X if applicable) COVID-19 Status (Active, Recovered, Deceased) Directing Authority (PCM, PHEO, DOD Policy, etc) Reason quarantine/isolation comments are required (Must submit updated comments as required)

Fill in this section for ALL CAT A only your tracking ID leave blank CTR DDGM Oconus Self Isolation Guam Home 4-Sep-20 12-Sep-20 X Recovered DOD Guidance Employee traveled from a high risk country- UPDATE 12 Sept employee completed 14 days of isolation. Returned to duty 12 Sep EXAMPLE ONLY your tracking ID CTR DDBC Conus Self Isolation Barstow, CA Home 4-Sep-20 TBD X Active Public Health Authority Employee was in contact with a COVID postive employee and is now Symptomatic- was tested and awaiting results. Last day in the office was 4 Sep EXAMPLE ONLY your tracking ID CTR DDJF Conus Quarantine Jacksonville, FL Hospital 4-Dec-20 TBD Sick Leave 2-Sep-20 X 4-Dec-20 positive Covid caused the hazmat office to close down for 3 days for cleaning- 3 days of processing hazmat has stopped (example) CAT A caused 5 other employees to self quarantine due to exposure- cross leveling isnt an option (example) Active ER Physician Employee felt ill and went to the ER, was tested and came back positive. Was admitted to hospital for further evaluation/treatment (example) EXAMPLE ONLY

Q tracker instructions

1. Submit your Q tracker with any changes highlighted since your last submission.

2. Highlight your "recovered" employees for 1 submission and then delete them on subsequent submissions.

3. Continue submitting your Q tracker daily with any updates until employee is recovered- then no more Q tracker is due

Definitions

CAT A: Individuals with confirmed COVID-19 infection, meaning they have tested positive for COVID-19 or have been diagnosed with COVID-19 by a healthcare provider

CAT B: Individuals who have been ordered into mandatory quarantine by a competent public/military health authority (either by virtue of exposure to COVID-19 or travel to/from a location with a confirmed outbreak).

CAT C: Individuals in a “stay at home” status, meaning they meet the conditions in a specific CDC or public health advisory to “stay at home” for 14 days, e.g., traveling from a high-risk country/region (Level 3 Travel Health Notice, Widespread, Ongoing Transmission).

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DRAFT

SAMPLE

PREVIOUS EDITION IS OBSOLETE.

DD FORM 3112, APRIL 2020

Page of

PERSONNEL ACCOUNTABILITY AND ASSESSMENT NOTIFICATION FOR CORONAVIRUS DISEASE 2019 (COVID-19) EXPOSURE

OMB No. 0704-0590 OMB approval expires 20201031

The principal purpose of this form is to collect information used in response to the public health emergency pertaining to the Coronavirus Disease 2019 (COVID-19) to protect the health and safety of individuals working in, residing on, or assigned to DoD installations, facilities, field operations, and commands, and to protect the DoD mission. When authorized by DoD, this form may be used to provide information about individuals who are infected or otherwise impacted by this public health emergency or similar occurrence or when there is an isolated incident in which an individual learns they have been exposed to the COVID-19 virus. The information submitted about the Affected Individual will be maintained in accordance with the Privacy Act of 1974. A Privacy Act statement is provided on page 3 of this form.

SECTION I: SUBMITTER INFORMATION

SECTION II: AFFECTED INDIVIDUAL INFORMATION

4. ASSIGNED DoD COMPONENT (Check one and list component)

5. PRIMARY WORK LOCATION

6. TRAVEL WITHIN THE LAST 30 DAYS? (Outside local commuting area)

7. TYPE OF CONFIRMED OR POSSIBLE HEALTH/SAFETY ISSUE

8. SYMPTOMS (Check one)

9. CURRENT STATUS (Check one)

SECTION III: FOR AGENCY USE ONLY

INSTRUCTIONS

SECTION I - SUBMITTER INFORMATION

This section is to be filled out by either the Affected Individual or the individual reporting about the Affected Individual. It could be filled out by a supervisor, agency representative, a contracting officer representative, or in the event that the Affected Individual was a visitor to a DoD facility, the DoD employee who sponsored the individual.

1. Date Report Submitted: Date report was submitted.

2. Full Name of Submitter: Enter full name of the individual submitting the report.

3. Relationship to the Affected Individual: Check the appropriate block.

4. DoD Component / Office of Submitter: DoD Component and Office of Submitter are most relevant when the person submitting the information is a representative from the Affected Individual's agency.

5. Job Title of Submitter: Enter job title of person submitting the form.

6. Phone Number: Enter best contact number.

7. E-mail Address: Enter best contact e-mail address. Contact information is required in the event there are questions about the information submitted on the form.

SECTION II: AFFECTED INDIVIDUAL INFORMATION

Accurate completion of this section will inform decisions made about the status of DoD facilities and spaces that the Affected Individual has entered. This information may be used to make decisions to protect the health and safety of DoD personnel and facilities. It may also be used to notify other individuals who may have contacted the Affected Individual.

1. Full Name of Subject: Enter full name of the Affected Individual, or individual affected by the disease or agent.

2. DoD ID #: Enter DoD ID#, which can be found on the back of the individual's Common Access Card or the front of the individual's Military ID.

3. DoD Affiliation: Enter the Affected Individual's DoD affiliation (military Service member, civilian, contractor, dependent / family member, retiree, other)

4. Assigned DoD Component: Enter the DoD Component to which the Affected Individual is assigned. If the Affected Individual is a military Service member, they may be assigned to their branch of service or to another DoD Component.

5. Primary Work Location: List the Affected Individual's primary work location and the facilities to which they have access.

6. Travel within last 30 days?: Identify whether or not the Affected Individual has traveled outside of the local commuting area with the last 30 days. Include the location(s) and date(s) of travel if applicable.

7. Type of Confirmed or Possible Health/Safety issue: Provide the specific type of communicable disease related to a public health emergency. For purposes of this form, a communicable disease is COVID-19.

8. Symptoms: Choose one option; if the Affected Individual has symptoms of COVID-19, include the date the symptoms began. If the Affected Individual was in contact with someone with symptoms, include the date of their potential exposure, if known.

9. Current Status: Choose the current status of the Affected Individual. If they are self-isolating, include the reason why. If they are under quarantine, include who directed them to quarantine; provide the date that the quarantine or self-isolation began, if applicable.

SECTION III - FOR AGENCY USE ONLY

This section is for use of the agency that is collecting and processing this form.

1. Name of Call Taker: Individual who is processing the form.

2. Affiliation/Organization: Enter call taker's affiliation and/or organization.

3. Phone Number: Enter best contact number.

4. E-mail Address: Enter best contact e-mail address.

5. Status on recovery and return to work: May be used to input the status of the Affected Individual's recovery and their return to work status.

6. Notes: This section is for receiving agency to use to include any notes.

TERMS & DEFINITIONS

Public Health Emergency. An occurrence or imminent threat of an illness or health condition that poses: A high probability of a significant number of deaths in the affected population considering the severity and probability of the event; A significant number of serious or long-term disabilities in the affected population considering the severity and probability of the event; widespread exposure to an infectious or toxic agent, including those of zoonotic origin, that poses a significant risk of substantial future harm to a large number of people in the affected population; health care needs that exceed available resources; or severe degradation of mission capabilities or normal operations.Call-Taker. Individual who receives/processes the form on behalf of the installation commander or senior DoD official.

Affected Individual: The individual who has symptoms from or been diagnosed with a communicable disease, who has been in contact with someone who has been diagnosed with a communicable disease, or has traveled to a location where there is a high risk of exposure to a communicable disease.Communicable Disease. An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent or its products from an infected or Affected Individual, animal, or a reservoir to a susceptible host, either directly or indirectly through an intermediate animal host, vector, or the inanimate environment. A communicable disease for purposes of this form is COVID-19.

Isolation. The separation of sick people with a contagious disease from people who are not sick.

Self-Isolation. When an individual voluntarily separates themselves from people who are not sick to prevent the spread of a communicable disease.

Quarantine. The separation of an individual or group that has been exposed to a communicable disease, but is not yet ill, from others who have not been so exposed, in such manner and place to prevent the possible spread of the communicable disease.

PRIVACY ACT STATEMENT

Authority: 10 U.S.C. 113, Secretary of Defense; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 8013, Secretary of the Navy; 10 U.S.C. 9013, Secretary of the Air Force; 10 U.S.C. 2672, Protection of Buildings, Grounds, Property, and Persons; DoD Instruction 6200.03, Public Health Emergency Management (PHEM) Within the DoD; and DoD Instruction 6055.17, DoD Emergency Management (EM) Program.

Principal Purpose: To accomplish personnel accountability and conduct status assessments for DoD-affiliated personnel during a public health emergency, including a pandemic, major public health outbreak, or similar crisis, or when directed by the Secretary of Defense. Information will be used to inform the agency's response to the emergency, including measures to ensure the safety and protection of the workforce and workplace.

Routine Use(s): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records may specifically be disclosed outside of DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3), including as follows: To persons, organizations, or governmental entities (e.g., other Federal, State, territorial, local, or foreign, or international governmental agencies or entities, first responders, American Red Cross, etc.), as is necessary and relevant to notify them of, respond to, or guard against a public health emergency, or other similar crisis. To contractors, grantees, and others performing or working on a contract, grant, or similar assignment for the federal government when necessary to accomplish an agency function related to this system of records.

A complete list of routine uses may be found in the applicable System of Records Notice (SORN), DPR 39 DoD, “DoD Personnel Accountability and Assessment System,” at https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DPR-39-DoD.pdf.

Disclosure: Voluntary; however, failure to provide such information may hinder DoD's ability to respond effectively to the public health emergency or crisis, thereby increasing the health or safety risk to DoD-affiliated personnel and its facilities. Failure to provide such information may also result in restricting the Affected Individual's access to DoD facilities.

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

9.0.0.2.20120627.2.874785 whs.mc-alex.esd.mbx.dd-dod-forms@mail.mil

ASD(HA)

DD Form 3112, "PERSONNEL ACCOUNTABILITY AND ASSESSMENT NOTIFICATION FOR CORONAVIRUS DISEASE 2019 (COVID-19) EXPOSURE"

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1. NAME OF CALL TAKER (Last, First, Middle Initial):

2. AFFILIATION/ORGANIZATION:

3. PHONE NUMBER:

3.a. IF OTHER, DESCRIBE:

4. EMAIL ADDRESS:

5. JOB TITLE OF SUBMITTER:

6. PHONE NUMBER:

7. E-MAIL ADDRESS:

Office of Secretary of Defense (e.g. P&R, A&S) : 0

OfficeofSec-TextBox:

Defense Agency (e.g. DISA, DMA): 0

DefAgency-TextBox:

Field Activity (e.g. OEA, WHS): 0

FieldAct-TextBox:

Military Service (list Branch of Service): 0

MilServ-TextBox:

OTHER (explain): 0

OTHER (explain): 0

OTHER (explain): 0

Other-TextBox:

NATIONAL CAPITAL REGION (NCR):: 0

PENTAGON: 0

MARK CENTER: 0

DHHQ: 0

MILITARY INSTALLATION: 0

LEASED FACILITY: 0

CONUS (Other than NCR):: 0

STATE:

MILITARY INSTALLATION:

OCONUS:: 0

LOCATION:

11. FACILITY ACCESS (list all facilities that the Affected Individual has access to): :

No: 0

Yes: 0

DATE RETURNED FROM TRAVEL:

COMMUNICABLE DISEASE (e.g. Smallpox, Cholera, COVID-19): 0

Comm-TextBox:

SYMPTOMATIC (Exhibiting symptoms): 0

DATE SYMPTOMS BEGAN:

ASYMPTOMATIC (No symptoms): 0

DATE OF POTENTIAL EXPOSURE:

SELF-ISOLATING (Provide reason):: 0

CLOSE CONTACT: 0

RECENT INTERNATIONAL TRAVEL: 0

DIRECTED QUARANTINE (By whom?): 0

ByWhom-TextField:

HOSPITAL: 0

IF THE AFFECTED INDIVIDUAL IS SELF-ISOLATING OR UNDER QUARANTINE, WHEN DID THEY START?:

5. STATUS ON RECOVERY AND RETURN:

6. NOTES:

SPECIAL SITREP #

FY-21-XX

Location of Incident:

Type of Incident

CAT III CCIR #16 Critical Readiness and Sustainment Issue

Initial:

Follow-Up:

Final:

Corrective:

Date/Time/Group Event

24 NOV 20 1324Z

Date/Time/Group

Date/Time/Group

24 NOV 20 1324Z

Date/Time/Group

Mission Impact:

Corrective Action Required/Taken:

HQ DLA Distribution assistance required: No assistance required at this time.

Contact Information

Reporter Information

POC for Further Information

Name:

Name:

Phone:

Com:

Phone:

FAX:

FAX:

E-Mail:

E-Mail:

Courtesy Copy Sent To: Contracting Officer and Acquisition Specialist

For all CAT A, the Contractor shall immediately submit one ENCRYPTED NIPR email containing the following information and attach Attachment 2 - DD Form 3112 (Attachment 2), and CAT III CCIR #16, Attachment 3 - Special SITREP (Any critical readiness and sustainment issues that are, or may, impact mission support). The SITREP will address mission impact, the employees last day of work (date), if the employee was at a DLA worksite within the last 14 days of CAT A diagnosis, and NOT contain any PII. Send email to the Distribution Center Commander/Director and COR.

- Block 7 - Inspection and acceptance requirements: The COR and Distribution Center Leadership will review and accept the Travel Quarantine-Isolation Tracker daily and submit to DLA Distribution. Headquarters.

- Block 14 - Distribution - Contractor to submit original to COR/Distribution Center Leadership and copy Contracting Officer/Aquisition Specialist Attachment 1 – Travel Quarantine-Isolation Tracker Attachment 2 - DD Form 3112 Attachment 3 - Special SITREP Form