UTSI SELF-ISOLATION FORM

Employees and students are to self-isolate and complete a self-isolation form if they:

  • Have tested positive for COVID-19;
  • Develop symptoms of a COVID-19 infection (In the last 48 hours, have you had at least two of the following symptoms which are new or not explained by pre-existing condition: fever, chills, repeated shaking chills, fatigue, muscle pain, body aches, headache, sore throat, nasal congestion, runny nose, vomiting, diarrhea, or loss of taste or smell, cough, shortness of breath, or difficulty breathing);
  • Are awaiting COVID-19 test results;
  • Are a close contact with someone  diagnosed with COVID-191 in last 14 days;(Close contact means within about 6 feet of a person diagnosed with COVID-19 for cumulative total of 15 minutes or more over a 24-hour period);
  • Have been advised to self-isolate/quarantine by a healthcare authority;
  • Need to self-isolate after traveling in accordance with the latest CDC travel guidance.

 

1People who are fully vaccinated do NOT need to quarantine after contact with someone who had COVID-19 unless they have symptoms. However, fully vaccinated people should get tested 3-5 days after their exposure, even if they don’t have symptoms and wear a mask indoors in public for 14 days following exposure or until their test result is negative.

Those who have recently traveled within the United States should decide whether they need to self-isolate based on the state and local travel restrictions and the rate of community spread to which they have been exposed.  Up-to-date information and travel guidance are available online from state and local health departments. 

All self-isolating faculty, staff, and students will promptly and accurately complete the self-isolation form. If he/she is unable to, the supervisor or advisor must complete the form. The form gives university staff the necessary information to respond appropriately.  After submitting the form, you will be contacted by the HR office to either provide or gain additional information. If need assistance, please contact the UTSI HR office at 931-393-7226 or hr@utsi.edu.

First Name
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Current Date
Field is required!
Field is required!
E-mail Address
Field is required!
Field is required!
Daytime Phone Number
Field is required!
Field is required!
Faculty, Staff, Student:
Field is required!
Field is required!
Personnel or Student ID Number:
Field is required!
Field is required!
Dept:
Field is required!
Field is required!
Current place of residence:
Field is required!
Field is required!
Supervisor/Advisor Name:
Field is required!
Field is required!
Supervisor/Advisor E-mail Address
Field is required!
Field is required!
With supervisor/advisor approval, do you have Ability to Telework?
Field is required!
Field is required!
Are you fully vaccinated?
Field is required!
Field is required!
If yes, date fully vaccinated
If yes, date fully vaccinated
Field is required!
Field is required!
Have you previously tested positive for COVID-19?
Field is required!
Field is required!
Date tested positive:
DATE
Field is required!
Field is required!
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 if 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.
Why are you self-isolating?
Field is required!
Field is required!
ISOLATION START DATE
ISOLATION START DATE
Field is required!
Field is required!
CONTACT/EXPOSURE DATE/DATE SYMPTOMS BEGAN
DATE
Field is required!
Field is required!
COVID-19 TESTING – Test 5 days or later after last contact or started experiencing symptoms of COVID-19 – First available date to test (Computed using contact date)
DATE
Field is required!
Field is required!
On what date were you tested or will be tested? This date is important, because it will determine the length of your quarantine if your result is negative.
DATE
Field is required!
Field is required!
ISOLATION END DATE
Negative test result - Return to work after day 7 after receiving a negative test result; the test must be administered on day 5 or later after exposure. Example: Self-Isolation starts on January 1 return to work on January 8. NOTE: If you get tested prior to day 5, your quarantine period will be 10 days.
If test is negative, you can return to work on:
DATE
Field is required!
Field is required!
Positive test result - Return to work after day 10 and have been fever-free for a minimum of 24 hours and your symptoms, if any, must be steadily improving. Must also have a written doctor’s approval to return to work. Example: Self-isolation starts on January 1, return to work on January 11.
If test is positive, you can return to work on:
DATE
Field is required!
Field is required!
If received test results, on what date?
DATE
Field is required!
Field is required!
Test results for COVID-19 - Please provide copy of the results to the UTSI HR office – hr@utsi.edu.
CONTACT TRACING
For contact tracing purposes, check the block(s) below regarding your reason for isolating:
Field is required!
Field is required!
Were you on campus 2 days prior to the start of your symptoms or your positive COVID-19 specimen collection date?
Field is required!
Field is required!
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.
Field is required!
Field is required!

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.