Self-Isolation Form "*" indicates required fields First Name* Last Name* Current Date* MM slash DD slash YYYY Email* Phone*Faculty, Staff, Student:* Faculty Staff Student Personnel or Student ID Number* Department* Current Place of Residence* Supervisor/Advisor Name* Supervisor/Advisor Email* Are you fully vaccinated? (1)* Yes (2) No If yes, date fully vaccinated:* (1) In general, you are considered fully vaccinated: 2 weeks after your second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine. If you don’t meet these requirements, regardless of your age, you are NOT fully vaccinated. Keep taking all precautions until you are fully vaccinated. (2) If fully vaccinated you do not need to quarantine after contact with someone who has COVID-19, unless you have symptoms of the virus. Even if you don’t develop symptoms, get tested 5 days after exposure and wear a mask indoors or in public for 10 days following exposure or until your test result is negative. Have you previously tested positive for COVID-19?* Yes No Date tested positive (3)* (3) If you have previously tested positive for COVID-19 and completed isolation you do not need to self-isolate or be tested again for up to three months as long as you do not develop symptoms again. If you develop symptoms again within three months of a COVID-19 diagnosis or it has been over three months since your last positive test, you need to self-isolate and be tested.With supervisor/advisor approval, do you have Ability to Telework?* Yes No Why are you self-isolating?* Were in close contact with someone diagnosed with COVID-19 (Close Contact is defined as being less than 6 feet away from an infected person (laboratory-confirmed or clinical diagnosis) for a cumulative total of 15 minutes or more over a 24-hour period. For example, three individual 5-minute exposures for a total of 15 minutes). Need to self-isolate after traveling in accordance with the latest CDC travel guidance. Tested positive for COVID-19 Are awaiting COVID-19 test results Develop symptoms of COVID-19 infection (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea). Have been advised to self-isolate by a health authority. Isolation Start DateIsolation Start Date Date of last contact/ exposure or started experiencing symptoms of COVID-19? COVID-19 TESTING – Test 5 days or later after last contact or started experiencing symptoms of COVID-19 – First available date to test (Compute using contact date) On what date were you tested? Isolation End DateWhat were the test results? Negative. If test result is negative, you can return to work. Positive. If test result is positive, return to work after day 5 of receiving positive test result and have been fever-free for a minimum of 24 hours and your symptoms, if any, must be steadily improving. Example: Results received on 1 January 2022, return to work on January 6, 2022. On what date did you receive your test results? If test result is positive, you can return to work on: Testing for COVID-19 - Please provide copy of the results to the UTSI HR office – hr@utsi.edu. Contact TracingFor contact tracing purposes, check the block below regarding your reason for isolating:* Were in close contact with someone diagnosed with COVID-19 (Close Contact is defined as being less than 6 feet away from an infected person (laboratory-confirmed or clinical diagnosis) for a cumulative total of 15 minutes or more over a 24-hour period. For example, three individual 5-minute exposures for a total of 15 minutes). Need to self-isolate after traveling in accordance with the latest CDC travel guidance. Tested positive for COVID-19 Are awaiting COVID-19 test results Develop symptoms of COVID-19 infection (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea). Have been advised to self-isolate by a health authority. Have you been on campus 2 days before your symptoms began or 2 days before you test if you do not have symptoms?* Yes No If yes, for contact tracing purposes, where on campus have you visited and with whom? Please be specific to building(s) and room(s) and people.Per OSHA guidelines, faculty, staff, and student workers that have tested positive for COVID-19 and feel it was contracted in the workplace, should report the positive test to their supervisors and to CorVel’s 24/7 call line at 866-245-8588. For more information about workers’ compensation, next steps, and forms, visit the UT System risk management website. Also, contact the UTSI Workers Comp Coordinator – Pam Ledford, hr@utsi.edu.PhoneThis field is for validation purposes and should be left unchanged.