UT System Administration Employees: Self-Isolation and COVID-19 Notice

Questions marked with a * are required

80%

This form is to be completed when an employee of the UT System Administration is requesting an alternative work schedule; requesting annual, sick or administrative leave; or is absent for reasons related to COVID-19. This form may be completed by the affected employee or the affected employee's supervisor.

Anyone with questions is encouraged to contact the UT System Office of Human Resources by emailing systemhr@tennessee.edu or by calling 865-946-8847.

Type of Request (Select all that apply)

Alternate Work Schedule (for example, requesting to work hours outside of those previously approved)

Annual, Sick or Administrative Leave

Absent

Other

Please explain

Employee's Contact Information

First Name

Last Name

Personnel Number

Work Phone

Personal Phone

Work Email Address

Personal Email Address

Department

Contact Information for Employee's Direct Supervisor

First Name

Last Name

Work Phone

Personal Phone

Work Email Address

Reason for Request (Select all that apply to the employee)

I have been diagnosed with COVID-19 (Supporting documentation required, submission tool on next page)

I have had close contact with someone diagnosed with COVID-19

I (or a dependent) have a suppressed/compromised immune system and am self-isolating to limit exposure (Supporting documentation required, submission tool on next page)

I have recently traveled to an area with confirmed cases of COVID-19 and was potentially exposed to the virus (Refer to https://www.cdc.gov for a list of locations with confirmed cases)

I have been asked by a healthcare provider to self-observe, self-monitor or actively monitor symptoms compatible with COVID-19 (Supporting documentation required, submission tool on next page)

I have symptoms compatible with COVID-19 but have not consulted a healthcare provider (Refer to https://www.cdc.gov for a list of symptoms)

I am voluntarily self-isolating. (Without documentation of potential exposure or symptoms that meet CDC guidelines for COVID-19 that result in a self-quarantine recommendation.)

I have a unique situation related to COVID-19 and am requesting consideration (Please explain using the comment box that will appear below)

Please explain