Attachment 9 CONTRACTOR Entry Form_v4.docx
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- N62470-20-R-1004
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CONTRACTOR/NON-NNSY GOVERNMENT EMPLOYEES TRAVEL ENTRY AUTHORIZATION FORM
Visitors answering “YES” to Question 3 of CUSFF/NAVNORTH COVID-19 Screening Questionnaire (V2020.04.18) shall complete the following to assist in access determination:
Contractor Company/Tennant Command
Contract Number (if contractor)
Origin (state & county)
Destination (NNSY, NOB, KSO, etc)
| # |
| I affirm that I: |
| Yes |
| No |
| N/A |
| 1 |
| Traveling from a location that utilizes CUSFF/NAVNORTH COVID-19 SCREENING QUESTIONNAIRE. If “No” see block 1A |
| |_| |
| |_| |
| 1A |
| If block 1 is marked “Yes” skip and go to block 2. Traveled from a state, which is not rated as “Significant to High” or “High” risk of COVID19 transmission as determined, by the NMCPHC COVID-19 State Surveillance Report. (Note: CAC required. Gov’t POC to assist with proper response.) |
https://esportal.med.navy.mil/sites/nmcphc/pps/COVID19/COVID19%20State%20Surveillance%20Medical%20Intel.pdf
| |_| |
| |_| |
| 2 |
| Will travel via personal or rental car. |
| |_| |
| |_| |
| 3 |
| WILL NOT use commercial taxi or other public transportation. |
| |_| |
| |_| |
| 4 |
| Will avoid close contact with other individuals if picking up a rental vehicle. (N/A if POV) |
| |_| |
| |_| |
| |_| |
| 5 |
| Will wash hands or used hand sanitizer upon completion of transaction prior to entering vehicle if renting a vehicle. (N/A if POV) |
| |_| |
| |_| |
| |_| |
| 6 |
| Will Wipe down the interior of the car. (N/A if POV) |
| |_| |
| |_| |
| |_| |
| 7 |
| Will minimize contact with others by stopping only when necessary. When making stops, ensured hygiene and sanitation measures are in effect, including |
- wipe down handles on gas pumps
- wash hands or used hand sanitizer after stops prior to re-entering vehicle
- utilize drive-thru restaurant services
- when stopping at restrooms, select bathrooms that are not high volume areas
- avoid close contact with others
| |_| |
| |_| |
| 8 |
| Will avoid close contact with individuals when dropping off rental vehicle. (N/A if POV) |
| |_| |
| |_| |
| |_| |
| 9 |
| Will wash hands or used hand sanitizer upon completion of transaction prior to entering personal vehicle. |
| |_| |
| |_| |
| |_| |
| 10 |
| Will, upon arriving at the final destination, follow CDC guidelines for sanitizing self and home/residence/hotel. |
| |_| |
| |_| |
| 11 |
| Will, upon arriving at NNSY site, speak with my Government POC |
___________________________ who will conduct a screening via phone, which includes the details of stops and social distancing practices used during travel and will verify through the screening that I maintained social distancing and hygiene practices during travel.
| |_| |
| |_| |
NOTES:
1) Personnel will show this Travel Entry Authorization Form for remainder of 14 day period when accessing NNSY or any NNSY off-yard facility.
2) Personnel answering “No” to any question from 1A through 11 will be denied access and should shall self-quarantine for the required 14 days unless a waiver has been submitted by the COR and approved by the appropriate agency (e.g. ,TYCOM).
3) If unable to meet these criteria then this form is no longer valid and I will inform my supervisor.
4) For NFPC the criteria of “Traveled from a state, which has equal to or lower risk of COVID19 transmission” will be substituted in Question 1.a. above.
Authorization to enter shall be documented on the following page.
Name (Print) Contractor/Non-NNSY Govt. Employee
Sign
Date
CONTRACTOR/NON-NNSY GOVERNMENT EMPLOYEES TRAVEL ENTRY AUTHORIZATION FORM (CONT.)
FOR GOVERNMENT USE ONLY
________________________________ is authorized entry to Norfolk Naval Shipyard or any NNSY off-yard facility despite an affirmative answer (“YES”) to Question 3 of the CUSFF/NAVNORTH COVID-19 SCREENING QUESTIONNAIRE (V2020.04.18). This determination is based on assessing comparatively equivalent or lower risk between the subject’s state of origin and destination location (Norfolk Naval Shipyard or NNSY off-yard facility) based on the Navy and Marine Corps Public Health Center (NMCPHC) Assessment (footnote 4 of V2020.04.18 questionnaire). The mode of travel has been assessed and determined not to have increased exposure risk.
Risk Level (Based on NMCPHC COVID-19 State Surveillance Report)
Origination:
Destination:
By signature below (electronic or hard copy), Government POC verified travel protocol has been followed. If block 1A is, marked “Yes” Government POC shall verify equal or lower state risk rating (state of origin compared to destination state) by referencing NMCPHC COVID-19 State Surveillance Report to validate.
|_| Access Granted |_| Access Denied (ROM 14d) |_| Access Requires Waiver (See Below)
Name (Print) Cognizant Point of Contact (same as page 1, question 11)
Sign
Date
IF WAIVER IS REQUIRED:
|_| Waiver Approved (Identify conditions and attach to this form)
|_| Waiver Denied
Name (Print) TYCOM/ Appropriate Agency Point of Contact
Sign
Date
ISSUE DATE
EXPIRATION DATE
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