Fillable Travel Questionnaire_FRCSE.pdf

7 April 2020

Naval Air Systems Command Headquarters and Supporting Commands

COVID-19

PRE-TRAVEL FORM

The safety of our employees, both Government and Contractor, remain our utmost priority. As the COVID-19 outbreak continues to evolve, we continue to monitor the situation and adjust procedures accordingly. The below questionnaire is required prior to entry onto the installation.

In order to prevent the possible spread of COVID-19 and reduce potential risk of exposure, we have implemented this screening process.

Please check either “yes” or “no” to the following six questions.

Yes No

1 Are you currently experiencing any of the following symptoms?

(fever, cough, sore throat and / or shortness of breath)

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, in a confined space, or direct contact with secretions) with anyone known to be infected with COVID-19?

4 Have you traveled OCONUS in the last 14 days?

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

6 Have you been to any location where local authority has ordered a ‘shelter in place’?

If you answered “yes” to ANY of the questions numbered 1 through 5, please do not execute your travel. If you answered ‘yes’ to only question number 6, and you are a Contractor employee, the Government Sponsor* will notify you of whether travel is allowable. If you are a Government employee, please notify your supervisor.

If you answered “no” to ALL of these questions before travel and at time of access, you will be granted access. Please note, based on a rapidly changing conditions, travelers may encounter additional on site self-isolate restrictions upon arrival. Please contact with your Government Sponsor for the most current details.

Please complete this questionnaire and if you are a contractor employee, provide your response to your Government Sponsor 24 hours in advance of this travel event. It is suggested you bring a copy of this questionnaire in the event it is requested for viewing. If you are a Government employee, please provide this completed questionnaire to your supervisor.

* A Government Sponsor is the requiring activity employee who is directly responsible for the travel event. This may be a COR, TPOC, IPT Lead or any other PMA/Command requiring activity personnel who is responsible for the contract travel requirement.

NOTE: The Center for Disease Control and Prevention (CDC) recommends wearing cloth face-coverings in public settings where other physical distancing measures are difficult to maintain, especially in areas of significant community-based transmission. The website, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html, has methods to make your own face-covering.

Face coverings will:

• fit snugly but comfortably against the side of the face

• be from nose to chin – full face coverings (like ski masks) are not authorized

• be secured with ties or ear loops

• preferably include multiple layers of fabric if material is cloth

• allow for breathing without restriction