Attachment J11 - COVID19 Visitor Questionnaire at JL.pdf
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- Solicitation number
- FDA-SOL-1224382
About this file
This document contains a visitor questionnaire and risk assessment for Jefferson Labs during the COVID-19 pandemic. The questionnaire requires visitors to provide their name, the name of the sponsoring JL staff and division, approving official, and travel history for the past three weeks. It asks whether the visitor has been in contact with or within six feet of someone diagnosed or suspected of having COVID-19 or been quarantined, and whether they have a fever, cough or shortness of breath. The JL staff must complete and return the questionnaire within 48 hours prior to the visitor's arrival and email it to the specified FDA addresses.
The related federal contract opportunity is a solicitation from the FDA for the installation of a new water well at the National Center for Toxicological Research in Jefferson, Arkansas. The solicitation number is FDA-SOL-1224382 and seeks a contractor to construct a new production water well to supply the NCTR/Arkansas Regional Laboratory's water needs.
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Text version
Clinic Risk Assessment Questionnaire for Jefferson Labs (JL) Visitors Prior to their Arrival on Campus (Updated 30 June 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 48 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 mailto:NCTROHU@fda.hhs.gov mailto:NCTROHU@fda.hhs.gov mailto:Elvin.Sprankle@fda.hhs.gov mailto:Elvin.Sprankle@fda.hhs.gov
File details come from the government source that posted it. Updated .