Attachment 3 BARC Visitor Biosecurity Questionnaire_blank.pdf

BARC Animal Facility Visitor Biosecurity Questionnaire Please note that this form must be completed by visitors and must be submitted to Veterinary Services BEFORE they enter animal facilities. This form is valid for 7 days after initial submission. For longer term visitors of more than 30 days, please contact Dr.

Corrin Markey and Dr. Shakera Fudge.

Once this form has been completed, please email a copy directly to Dr. Corrin Markey at: corrin.markey@usda.gov and Dr. Shakera Fudge at: shakera.fudge@usda.gov.

Name: __________________________________________ Date(s) of Visit: __________________

Address: __________________________________________ Telephone #: ___________________

Job Title: __________________________________________

Purpose of the visit: __________________________________________________________________

Buildings to visit (please list building numbers): ____________________________________________

Sponsoring BARC Facility Employee: ____________________________________________________ (Employee name and Management Unit)

1) Have you, or any immediate family member or other individuals that you live with, been out of the country in the past 14 days?

☐ Yes ☐ No If yes, please provide name of country(s): ______________________________

If “yes”, did you visit a farm? ☐ Yes ☐ No

What type of farm and species did you visit? ________________________________________

2) In the past 5 days, have you had contact with livestock (i.e.: cattle, swine, poultry) or pet birds?

☐ Yes ☐ No

If “yes”, list Species: ________________________________________

3) If “yes” to either Item 1 or 2 above, have you followed proper decontamination procedures prior to your arrival at this Research Center? See steps below and answer “Yes” or “No”.

• My clothing has been freshly laundered or was not previously exposed to agricultural facilities;

• My footwear has been properly decontaminated (scrubbed with soap and water and cleaned of all dirt and debris) OFF the visitation site or has not been worn on agricultural facilities;

• I have showered with soap and shampoo; and

• I have cleared and cleansed my nasal passages.

☐ Yes, I have followed proper decontamination procedures. ☐ No, I have not.

Note: If in contact with swine or poultry within 72 hours, access to those facilities will be denied. If you answered yes to question #1, depending on country, access to animal facilities may be denied.

Visitor Acknowledgement: I acknowledge that I have answered the above questions honestly and to the best of my ability and by not answering truthfully, I potentially could breach biosecurity policy at the BARC location. I have had the opportunity to ask questions regarding the safety of entering the animal facilities and these questions have been answered to my satisfaction. I acknowledge that if any of my answers to the questions above change during the duration of my visit, I will notify Veterinary Services immediately before re-entering animal facilities.

Visitor signature: ________________________________________ Date: ____________________

Sponsoring employee signature: ____________________________ Date: ____________________