Attachment J10 - COVID19 Visitor Questionnaire at JL.docx

Clinic Risk Assessment Questionnaire for Jefferson Labs (JL) Visitors Prior to their Arrival on Campus (Updated 20 May 2020) (One per visitor) Effective June 1, 2020 and until further notice, EVERYONE entering the campus is required to wear a face covering. No exceptions! Thank you for your cooperation.

Visitor’s Name/Company:

Name of JL staff (sponsor/escort) and Division/Contractor:

Name of the Approving Official:

1. Has the JL staff member received approval from the supervisor or Division Director for the visitor? YES or NO

2. The JL staff member must provide a statement stating why the visitor is essential:

Statement:

3. The visitor must provide his/her travel history for the past 3-weeks; within and/or outside of the United States

4. Has the visitor been in contact with, or within 6 feet of a person diagnosed with or suspected of having the coronavirus disease, or quarantined for coronavirus disease? YES or NO

5. Does the visitor have fever (greater than 100.4 degrees Fahrenheit), cough or shortness of breath? YES OR NO

If yes, please list your symptoms:

It is the responsibility of the JL staff to have your visitor complete and return this questionnaire within 24 hours prior to their arrival on center and email to: NCTROHU@fda.hhs.gov and Elvin.Sprankle@fda.hhs.gov Please notify the OHU if the answers to the questions change prior to entry to center at 870-543-7333