Attachment J8 - COVID19 Visitor Questionnaire.docx

DOCX document 18 KB Posted

Attached to
Roof replacement, Building 15 and 53 A, B, C, D & Mech room in Jefferson, Arkansas
Solicitation number
75F40121R00014
Issued by

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This document contains a visitor questionnaire and risk assessment for Jefferson Labs along with details of a federal contract opportunity for roof replacement services. The questionnaire requires visitors to provide their travel history, disclose any potential COVID-19 symptoms or exposure, and gain approval from their sponsor and division director. It must be completed within 24 hours of the visit and emailed to the specified FDA recipients.

The roof replacement contract opportunity is for buildings 15, 53A, 53B, 53C and 53D as well as the mechanical room at the National Center for Toxicological Research facility in Jefferson, Arkansas. The solicitation is issued by the Department of Health and Human Services Food and Drug Administration Office of Acquisition and Grant Services. No further details are provided on response dates, award timing, pricing or other contract terms.

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75F40121R00014 Attachment J7 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

File details come from the government source that posted it. Updated .