Attachment 4 - Pre-visit-questionnaire.docx

PRE-VISIT QUESTIONNAIRE Version 14 January 2022

We ask people requesting access to our facilities follow NREL COVID-19 protocols intended to minimize potential exposure to COVID-19 (and current variants) while on-site. DOE requires all visitors, subcontractors, and any non-badged person to answer a few questions and provide proof of vaccination upon arrival at NREL. Acceptable proof may be the vaccination card or a photo of the vaccination card. If you cannot provide proof of vaccination, you will be required to provide a negative COVID test within 3 days of your visit. NOTE: Home COVID tests are not acceptable.

Are you fully vaccinated? (Check one) ______Yes ______No

If yes, please be prepared to bring proof of vaccination upon entry. Note: Final vaccination date must be at least 2 weeks prior to arrival date.

If no, please be prepared to bring negative COVID test results from within 3 days of your visit. NOTE: Home COVID tests are not acceptable.

Please answer the following questions within 3 days before your planned visit and send the completed form to COVID19@nrel.gov. You will be asked to confirm your answers when you arrive on-site.

1. Where have you traveled in the past four weeks?

Please list all countries: __________________________________________________ Please list all states: _____________________________________________________

2. Have you had contact with a person with a confirmed or a presumptive positive coronavirus case within the past 10 days?

(Check one) ___ Yes ___ No

Have you received a booster shot? ______Yes _____No

3. Do you have any symptoms of illness: fever, sore throat, cough, shortness of breath, loss of taste or smell, headache, runny nose, nasal congestion, body aches, rash, night sweats, abdominal pain, vomiting, diarrhea, or other symptoms?

(Check one) ___ Yes ___ No By signing this document, you agree to adhere to the on-site COVID safety protocols as noted on the second page of this form.

_______________________________________________________________________ Printed Name Signature Date

NREL On-site COVID-19 Protocols:

ALL PERSONS, regardless of vaccination status must:

· wear a mask indoors

· NOT come to campus if feeling ill

· Report immediately any new onset illness

· Report pending or recent positive COVID-19 test

· Report contact with probable or confirmed COVID- positive person.

You may remove your mask when:

· in an area separated by walls and a door.

· outside, as long you are 6 feet from another individual.

· eating and drinking inside and behind a closed door.

UNVACCINATED persons must:

· Wear masks at all times

· Maintain 6-foot distance from others when possible

· Eat meals alone in closed room or outdoors

· Not come to campus if had contact with someone ill or confirmed COVID-19 positive

· Not come to campus if have a COVID-19 test result pending at the time of the visit Additional Considerations:

· Avoid shaking hands.

· Minimize number of people involved to those that are essential.

· Minimize time in closed rooms/laboratories.

COVID Testing Locations

Any personally Identifiable information collected to track and control access to Departmental facilities is authorized under the Privacy Act, 5 U.S.C. 552a and System of Records DOE-51 - Employee and Visitor Access Control Records. Information collected is used to screen for possible COVID-19 symptoms or suspected exposure prior to site access, and to provide information, if needed, for epidemiological tracking should cases of COVID-19 be identified at NREL and/or GFO. Disclosure of information under this action is voluntary, however, failure to provide the requested information may result in denial of your access to the GFO/NREL site.

image1.png image2.png