Attachment 12 Visitor Contractor Wellness Check.pdf

ARS, Northeast Area Mission Critical/Time Sensitive Activities During Pandemic

Visitor/Contractor Daily Wellness Check Questionnaire

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7/23/2021 10:14 AM

All Visitors and Contractors entering or performing work at a USDA/Agricultural Research Service facility must complete a “Wellness Survey” each day they are onsite (some locations may use the ARS Check Survey in addition to this form) and before entering a building or facility. Should the Visitor/contractor respond “Yes” to a question they will be interviewed by the “Location Pandemic Coordinator” or their alternate to seek clarification on the “Yes” response. Based on the clarification, the individual(s) may not be allowed access to the facility.

Visitors/Contractors please provide the following contact Information:

Name:

Business:

Contact Number:

E-Mail Address:

Location POC Purpose of Visit:

Wellness Check – Please answer the following questions to the best of your knowledge for the current day.

1. In the last 14 days, have you traveled to or from a region outside of your regular commuting area where local ordinances required quarantine or other COVID-19 related travel mandates (e.g., test results, travel form/registration)?

Yes / No

2. Have you been diagnosed with, or experienced any symptoms of COVID-19 in the past 14 days or since last check in, including the following: fever (100.4 degrees F or greater), or chills, cough, loss of taste or smell, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?

Yes / No

3. Have you had close contact with anyone diagnosed with COVID-19 or showing symptoms of COVID-19 within the past 14-days? Close contact is defined as being within six feet of a person for more than 15 minutes within a 24 hour period.

Yes / No

Please return the completed questionnaire to your Point of Contact at the location on the day of arrival. If you have any questions, please contact them in advance of your arrival.