Attachment 11 - COVID19 Visitor Questionnaire.pdf

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 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