The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Professional Visitor Pre-Screening Questionnaire

This form must be completed between 72 and 48 hours immediately preceding the scheduled arrival of any vendor, consultant, contractor or other professional visitor at a Penn State Health Milton S. Hershey Medical Center or Penn State College of Medicine location. Note that by submitting this form, the visitor agrees to abide by all guidance for visitors/vendors as listed at med.psu.edu/vendors.

The visitors and internal representative will be notified of approval status.

Professional visitors should not arrive on site without notice of approval.

With any questions, contact BiosafetyOfficer@pennstatehealth.psu.edu.

Visitor first name

* must provide value

Visitor last name

* must provide value

Visitor company

* must provide value

Visitor email

* must provide value

Visitor city of residence

* must provide value

Visitor county of residence

* must provide value

Visitor state of residence

* must provide value

Are you fully vaccinated against COVID-19 (e.g., it has been at least two weeks since your second dose of the Pfizer or Moderna vaccine or at least two weeks after your Johnson & Johnson vaccine)? (Answer is optional; individuals who do not disclose vaccine status will be considered unvaccinated)

Yes

reset

Note: Unvaccinated individuals and/or those who elect to not disclose vaccination status are required to provide a negative COVID test obtained within 3 days of visitor arrival at the College of Medicine. This must be shown to the institutional Pandemic Safety Officer or escort.

Within the past three weeks, has the professional visitor traveled outside of their home area (the city, county and state listed previously)?

* must provide value

Yes

reset

List all dates within the past three weeks in which the visitor traveled outside their home area, and list specific locations traveled with each date. (One date per line.)

Include airport layovers, domestic and international locations, cruise or ship travel, etc.

Example:
- June 10, 2020 - BWI Airport, Maryland
- June 9, 2020 - Phoenix, AZ (airport, Best Western Hotel)

* must provide value

Expand

Does the visitor live in the same household with someone who is COVID-19-positive or who is symptomatic and awaiting COVID-19 test results?

* must provide value

Yes

reset

Has the visitor received a positive COVID-19 test or are they awaiting the results of a COVID-19 test?

* must provide value

Yes

reset

Date test was administered

* must provide value

M-D-Y

Date of positive result (if received)

M-D-Y

Does the visitor currently have any of these signs or symptoms? (Check all that apply.)

* must provide value

Fever (at or exceeding 100.4 degrees F/38 degrees C)

Chills

Sweats

Cough

Headache

GI symptoms

Conjunctival infection

Sore throat

Nasal congestion

Rhinorrhea

Dyspnea

Myalgias

Lung exam abnormalities

None of the above

Department with which visitor is working

* must provide value

List all room number(s) vendor/consultant/contractor will be utilizing, separated by commas.

Example:

C1742K, cafeteria, Junker Auditorium

* must provide value

Approximate number of individuals the visitor will directly interact with while on campus

* must provide value

Name of Penn State Health Milton S. Hershey Medical Center or Penn State College of Medicine representative coordinating with visitor

* must provide value

Email of internal representative coordinating with the visitor

* must provide value

Is the visit research-related?

* must provide value

Yes

reset

Purpose of visit: Please briefly explain why an in-person visit is essential and why the visit cannot be conducted remotely.

* must provide value

Expand

Name of PI on research study to which visit relates

* must provide value

Will the visitor be delivering any tangible supplies to campus?

* must provide value

Yes

reset

How and where will items be delivered/transported to the work area? Be as specific as possible.

* must provide value

Expand

Visitor scheduled arrival date and time

* must provide value

M-D-Y H:M

Visitor scheduled departure date and time

* must provide value

M-D-Y H:M

Choose "Yes" to confirm that the visitor will remain appropriately masked and physically distanced at all times while on campus. Visitors who do not select "yes" will not be approved to visit.

* must provide value

Yes

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.