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The purpose of this form is to allow for contact tracing to notify other UVM affiliates or operations if needed as well as to understand the scope of COVID-19's impact to business continuity to aid in planning. 

This form should be completed by the employee and only if they have been on campus in the last 14 days and they have been directed by their doctor to stay home due to COVID-19 symptoms or close contact. Individuals should follow the VT Department of health's Close Contact guidelines before contacting a health care professional. If the employee is unable to fill out the form, the supervisor can fill it out on the employee's behalf.

This reporting procedure applies to employees who have been suspected, presumed, or confirmed to have COVID-19 by a healthcare professional and have been in contact with UVM affiliates in the past 14 days. 

Students should not report on this form, but should call the Student Health Center at 656-3350 for assistance related to COVID-19.

Any personal health information disclosed on this form will be protected as required under applicable law. Access to personal information that you provide on this form will be limited to only those with a legitimate purpose/need to know.