Have you experienced any of the symptoms in the list below in the past 48 hours?
fever or chills
new or unexplained onset of cough, shortness of breath, or difficulty breathing
new or unexplained loss of taste or smell
new or unexplained muscle aches
This symptom list was developed using a scientific approach by CDC scientists who reviewed the literature and studies to determine which symptoms are most predictive of COVID-19. If you have had any of these symptoms in the last 48 hours, DO NOT physically return to the workplace until symptoms have been improving for more than 48 hours. If you have a medical condition that causes any of these symptoms and you need access to a CDC facility within the next few days, you will need a waiver from CDC’s Occupational Health Clinic (OHC). To begin the waiver process, please fill out a waiver request by completing the COVID-19 Waiver for Access to CDC Facilities (office.com) form.
Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?
If you have concerns about being exposed to or sick with COVID-19, please stay home and self-quarantine or isolate. Read more about when you should be in isolation or quarantine. If you have questions about when it is safe to return to the workplace, please call CDC's Occupational Health Clinic (OHC) at 404-639-3385. If you have an urgent need to end your quarantine early to access a CDC facility, please fill out a waiver request by completing the COVID-19 Waiver for Access to CDC Facilities (office.com) form.
Are You FULLY vaccinated* with the primary series for COVID-19?
OR
Have you recovered from a documented COVID-19 infection in the last 3 months?
*To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine. Visit "Stay Up to Date with Your COVID-19 Vaccines" for more information.
Are you up-to-date* with your COVID-19 vaccinations?
Answer “No” if one of the following applies to you:
It has been 5 months or more since you completed your primary series of Pfizer-BioNTech or Moderna and have not received a booster
It has been 2 months or more since you completed your primary series of J&J's Janssen and have not received a booster
Staff who are immunocompromised and/or 50 years or older ONLY: It has been more than 6 months since your first booster and you have not received your second booster
If the COVID-19 community level for the CDC facility you are entering is medium or high, do you attest that you have shown—or will show this the week—a COVID-19 PCR or professionally-proctored antigen test taken this week to your supervisor, Contracting Officer’s Representative (COR), or CDC supervisor/mentor?
Answer “Yes” if you are a visitor to CDC. You may be asked to show CDC Security a negative COVID-19 PCR or professionally proctored antigen test when you check-in
When the COVID-19 community level in the county where the CDC facility is located is medium or high, staff who are not yet fully vaccinated with their primary series are required to participate in CDC’s COVID-19 screening testing program. To do so, they must show results (electronic or hard copy) of a COVID-19 PCR test or professionally-proctored antigen test once per week for each week they are coming on-site to a CDC facility or interacting with the public on behalf of CDC (a week is Sunday through Saturday). The test must be taken and results provided to the supervisor/COR/mentor between Sunday and 1 p.m. Friday each week (if staff are coming on-site on a Saturday, they must provide results to their supervisor by 1 p.m. on Friday, the day before). Employees only need to provide one test result per week. Employees must show their test results to their supervisor in person or virtually via video chat. Do not email test results. Positive test results reported as part of CDC’s screening testing program must be reported. Visit the Case Reporting, Contact Tracing, and Staff Notification page for more information.
Visitors who are not fully vaccinated with their primary series or decline to provide verification they are fully vaccinated with their primary series may be required to show results (electronic or hard copy) of a negative COVID-19 PCR or professionally-proctored antigen test taken in the three days before coming on-site when the CDC facility’s COVID-19 community level is medium or high. If required, visitors must show verification of vaccination or proof of a negative COVID-19 test each day they visit. Visitors who do not provide valid verification of vaccination or a negative COVID-19 test when the community level is medium or high will not be allowed to access a CDC facility. CDC is not able to provide testing for visitors.
Have you been in close physical contact* in the last 10 days with anyone who has tested positive for COVID-19?
*Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection).
If you have been in close contact with someone with COVID-19 and you are up-to-date with your COVID-19 vaccines, you should get tested 5 days after your exposure and you should wear a mask indoors for 10 days, even if you don’t have symptoms. Read more about what to do if you’ve had a close contact and are up-to-date on your vaccinations. If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to request a waiver through CDC’s OHC. OHC will not respond to waiver requests made by individuals.
Have you been in close physical contact* in the last 10 days with anyone who has tested
positive for COVID-19?
*Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection).
If you have been in close contact with someone with COVID-19 and you are up-to-date with your COVID-19 vaccines, you should get tested 5 days after your exposure and you should wear a mask indoors for 10 days, even if you don’t have symptoms. Read more about what to do if you’ve had a close contact and are up-to-date on your vaccinations. If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to request a waiver through CDC’s OHC. OHC will not respond to waiver requests made by individuals.
Have you been in close physical contact* in the last 10 days with anyone who has tested
positive for COVID-19?
*Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection).
If you have been in close contact with someone with COVID-19 and you are NOT up-to-date with your COVID-19 vaccines, you should stay home and quarantine for at least 5 full days, get tested at least 5 days after your exposure, and you should wear a mask indoors for 10 days, even if you don’t have symptoms. Read more about what to do if you’ve had a close contact and are not up-to-date on your vaccinations. If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to request a waiver through CDC’s OHC. OHC will not respond to waiver requests made by individuals..
Did you have a negative COVID-19 test result from a test taken at least 5 days after your last exposure to the person who tested positive for COVID-19? (If it hasn't yet been 5 days since your last exposure, select "YES").
Individuals who are not up-to-date with their COVID-19 vaccines and had a close contact must stay home and quarantine for at least 5 full days and get tested at least 5 days after your last exposure with someone with COVID-19. If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to request a waiver through CDC’s OHC. OHC will not respond to waiver requests made by individuals.
Have you traveled internationally in the last 10 days?
Did you have a negative COVID-19 test taken at least 5 days after your last exposure to the person who tested positive for COVID-19? (If your exposure was less than 5 days ago, answer NO)
Individuals who are not up-to-date with their COVID-19 vaccines and had a close contact must stay home and quarantine for at least 5 full days and get tested at least 5 days after your last exposure with someone with COVID-19. If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to request a waiver through CDC’s OHC. OHC will not respond to waiver requests made by individuals.
Did you have a negative COVID-19 test taken at least 5 days after your last exposure to the person who tested positive for COVID-19? (If your exposure was less than 5 days ago, answer NO)
Individuals who are not up-to-date with their COVID-19 vaccines and had a close contact must stay home and quarantine for at least 5 full days and get tested at least 5 days after your last exposure with someone with COVID-19. If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to request a waiver through CDC’s OHC. OHC will not respond to waiver requests made by individuals.
Have you traveled internationally in the past 5 days?
Federal employees who make a false statement on this form could be subject to an adverse personnel action, up to and including removal from their position. It is also a federal crime (18 U.S.C. § 1001) for anyone to provide false information on this form. Falsification could also affect continuing eligibility for access to classified information or for employment in a national security position under applicable adjudicative guidelines.
CDC staff who fail to provide accurate information on this form may be subject to disciplinary action.
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