PWS Attachment 6 CTF COVID Screening Questionnaire.pdf

CTF COVID Screening Questionnaire

22 March 2022 Revision 6

Name:

NSWCPD GovernmentPOC:

Date Submitted: Visit Dates:

YES NO

YES NO

Organization/Company:

If you have answered YES to any of the above questions or have tested positive for COVID-19 within10 days of CTF visit, it is highly recommended that you telework (if eligible) or take appropriate leave. Contact your local supervisor/company/NSWCPD POC for final determination.

1. Have you or will you travel INTERNATIONALLY within 10 days prior to date of CTF visit?

2. Have you had close personal contact (within 6' for cumulative 15-mins in a 24-hr period) with anyone who has been diagnosed with COVID-19 within 10 days prior to date of CTF visit?

3. Are you currently experiencing or have you experienced any COVID-19 symptoms within 10 days prior to date of CTF visit?

4. Are you currently waiting on results of a COVID-19 test due to suspected exposure or based on experiencing symptoms?

5. Have you tested positive for COVID-19 within10 days prior to the date of CTF visit?

6. What geographical area (city and state) are you traveling from?

7. What geographical areas (city, state, country) have you or will you visit within 10 days of CTF visit?

8. How will you travel to CTF? Will you stop along the way? Where?

YES NO

NOYEYESS

Visitor Requirements:

• Wash hands frequently with soap and water for 20 seconds. Use hand sanitizer when soap and water are not available.

• Maintain 6ft social distancing with personnel if possible. Minimize visits to control room.

• Comply with current NSWCPD mask guidance. Have mask available for use if necessary.

• Conduct NSWCPD COVID screening self-assessment survey (posted at bldg 633 main entrance) each time entering the building.

• If you have tested positive within 10 days of CTF visit or have come in close contact (within 6' for cumulative 15-mins in a 24-hr period) a person who has tested positive within10 days of CTF visit, do not enter the building and consult with your supervisor.

• Report positive COVID cases to your NSWCPD POC.

• Submit this form for each visit to your NSWCPD POC and also to Enrico Giampaolo, 215-897-7285, enrico.giampaolo.civ@us.navy.mil at least two business days (Mon-Fri, except Federal Holidays) prior to arrival.

EYYESS NO