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To reduce the risk of COVID-19 exposure on campus, visitors and vendors should complete the health screening form as directed by the sponsoring department. Visitors and vendors are advised to stay home if they have symptoms of COVID-19, have recently tested positive for COVID-19, or think they may have been exposed to COVID-19.

UTK Health Screening Form for Visitors and Vendors

Please answer each question. You do not need to consider any chronic conditions you may have.



Sponsoring Department Information



(The final results, but not the answers to any of the screening questions, will be emailed to the Department Contact Person.)



Visitor/Vendor Information





For your privacy, answers to individual questions will not be stored. Your Sponsoring Department’s Contact Person does not receive your answers to these questions. Your Sponsoring Department’s Contact Person only receives the final determination. Self-assessment is not considered protected health information and as such is neither stored nor subjected to HIPAA protections. If at any time you cannot access this form, please self-screen and share the final result with your Sponsoring Department Contact Person using your preferred method of communication (email, text, or phone call).

If you have any questions or concerns about self-screening, please contact your Sponsoring Department’s Contact Person.

Have you been told to quarantine/isolate by a medical provider or the health department?



Are you currently awaiting COVID-19 test results?



Excluding those individuals in an occupational setting wearing appropriate professional PPE, in the last 14 days, have you had close contact (i.e. less than 6 feet of physical distance) for 10 minutes or more with someone who has COVID-19?



Are you experiencing a cough, shortness of breath, or difficulty breathing which is new or not explained by a pre-existing condition?



In the last 48 hours, have you had at least two of the following symptoms which is new or not explained by a pre-existing condition: fever, chills, repeated shaking chills, fatigue, muscle pain, body aches, headache, sore throat, nasal congestion or runny nose, vomiting, diarrhea, or loss of taste or smell?



Was your temperature 100.4 or above just prior to taking this self-screen?




By checking in, I agree that the information indicated above is correct.