Attachment F - Rev - 5100-82_PRETRAVEL_QUESTIONNAIRE-FILLABLE-6.21.22.pdf

Fleet Readiness Center East

PRE-TRAVEL & SITE ACCESS QUESTIONNAIRE

The safety of our employees, both Government and Contractor, remain our utmost priority at Fleet Readiness Center East. We have implemented a screening process in order to prevent the possible spread of COVID-19 and reduce potential risk of exposure. We require that all visitors to our facility complete the questionnaire below prior to travel & entry to our site. When complete, return it to the visitor's FRCE sponsor.*

Name: Requested Dates of Visit:

Yes No

1 Are you currently experiencing any COVID-19-like symptoms?

i.e., fever, cough, sore throat, shortness of breath, headache, scratchy throat or congestion

2 Have you experienced any of the above symptoms in the last 14 days?

3 In the past 14 days, have you had close contact (within 6 feet for 15 minutes or greater) with anyone who was symptomatic or positive for COVID-19?

4 Have you traveled OCONUS in the last 14 days?

If yes, location and date arriving in U.S.:_____________________________________________

5 Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

6 Where will you be traveling from immediately prior to arrival to the FRC East local area?

If you answered “yes” to ANY of the questions numbered 1 through 5, please do not travel until you receive guidance from the Sponsor. If number 6 includes OCONUS locations or areas in HIGH, the Government Sponsor* will notify you of any mitigations necessary for entry, which may include a delay in reporting on-site.

Please note, travelers may encounter additional on–site, mitigation requirements such as self-monitoring period upon arrival to the local area and prior to entry into FRC East work spaces. Please contact your Government Sponsor for the most up-to-date guidance within 72 hours of your visit.

Please provide your completed questionnaire to your FRCE Sponsor* at least 72 hours in advance of travel. Please also bring a copy of this questionnaire as it may be requested upon arrival.

*An FRCE Sponsor is the federal employee (COR, TPOC, IPT lead or any other FRCE Command representative) who is directly responsible for the travel or visit requirement.

The following requirements are for situational awareness:

• Masking and pre-visit testing may be required during the visit when the Community Levels dictate. Restrictions will include no group luncheons with FRC East employees or other activities that do not permit social distancing.

• FRCE Sponsor will ask for vaccination status in the documents provided by the visitor. If the visitor is unvaccinated or elects not to provide that information, the visitor will be subject to appropriate restrictions.

• Visitors coming from an OCONUS location (vaccinated or unvaccinated), may be delayed from access after arrival in the local area. The number of days will depend on the health status of the visitor’s departure location.

Sponsors should contact the FRCE Response Management Center Lead, Tracy Brooks at 252-464-5956 for guidance on self-monitoring periods. Questions on visitor access may be directed to Security at 252-464-6991.

Hard Copy or Digital Signature of Visitor

Updated JUNE 2022