Caregiver Name:
* must provide value
Employee Number:
* must provide value
if not employed by Intermountain, enter your role and who you work for.
Today M-D-Y
Have you been tested for COVID-19?
Yes
No
Positive
Negative
Waiting for Results
Positive
Negative
Waiting for Results
Do not return to work until you get your result. Have you notified Employee Health of your positive result?
Yes
No
Hidden by Suzy 1/13/2022 Please call Employee Health at 801-442-7547 Why were you tested for COVID-19?
I was sick
I was not sick, I tested because I was exposed to someone positive with COVID-19
I was not sick, tested for another reason (pre-op, work requirement, personal travel, etc)
I was sick
I was not sick, I tested because I was exposed to someone positive with COVID-19
I was not sick, tested for another reason (pre-op, work requirement, personal travel, etc)
Have you been exposed or in close contact with someone who has tested positive for COVID-19?
Yes
No
Do you have any symptoms today?
Yes
No
Testing Recommended. Contact your primary care provider (PCP) or Connect Care for COVID testing. Please check with your insurance carrier to learn if the test will be covered. You will receive the results from your COVID test in the order it was submitted. Your results will be available in the MyHealth+ app.
Do you work on a NICU, BMT unit or Childcare Center?
Yes
No
Do you work on a NICU or BMT unit?
Yes
No
Please follow Return to Work criteria found in "Known Exposures Special Populations (NICU, BMT unit or Childcare Center)" Was your exposure to COVID-19 someone living in your household?
Yes
No
Are you able to isolate yourself at home?
Isolation includes:
1. Stay away from others as much as possible, separate bedrooms and bathrooms 2. Avoid sharing personal household items. (dishes, drinking glasses, cups, eating utensils, towels or bedding)
Yes
No
Has your household member met all 3 CDC quarantine guidelines below?
5 days since symptoms started, AND 24 hours without a fever without using fever reducing medications, AND symptoms are improving
Yes
No
Did you meet the COVID-19 testing requirement to Return to Work?
Situation 1: Exposure outside of home or isolated from household member.
Testing Requirement: Negative PCR result taken a minimum of 2 days after exposure
Situation 2: Exposure to household member, unable to isolate
Testing Requirement: Negative PCR taken a minimum of 2 days after your household member meets CDC guidelines.
Yes
No
Has it been a minimum of 5 days from the onset of your symptoms?
Note: If you are a caregiver working in NICU, you must wait a minimum of 10 days before returning to work.
Yes
No
Has it been a minimum of 10 days from the onset of your symptoms?
Yes
No
Has it been a minimum of 5 days since your positive COVID test?
Yes
No
Has it been a minimum of 10 days since your positive COVID test?
Yes
No
Have at least 24 hours passed since your last fever without the use of fever-reducing medication?
Yes
No
Have at least 24 hours passed since your last fever without the use of fever-reducing medication?
Yes
No
Have your symptoms improved?
Yes
No
Have your symptoms improved?
Yes
No
Do you work in NICU or a Childcare Center?
Yes
No
Do you work on a BMT or NICU unit?
Yes
No
No work restrictions COVID Symptoms: Fever, runny or stuff nose, shortness of breath, new or worsening cough, body aches, reduced sense of taste or smell, sore throat, diarrhea.
You may not return to the NICU, BMT unit or Childcare Center until you receive COVID-19 PCR Test results. Testing must be a minimum of 2 days after your exposure. (recommended 2-4 days) Please speak with your leader about a temporary reassignment to another area until you meet criteria to care for your special population.
Contact Employee Health for a COVID test order.
Phone: 801-442-6767 or create a Service Now ticket.
You are able to return to work in the NICU/BMT Diligently wear your PPE at work and social distance from coworkers Hidden by Suzy 1/13/2022
Preferred email address:
You may return to work in the NICU, BMT unit or Childcare Center.
You have met Return to Work Criteria. You do not have any work restrictions. Please diligently wear your PPE. You have met Return to Work Criteria. You do not have any work restrictions. Please diligently wear your PPE.
*If you work in NICU, BMT or Childcare, see the specific instructions below for Known Exposures in Special Populations. If you are not eligible to return to your NICU, BMT unit, or Child Development Center yet, you may return to another area. Please coordinate with your manager.
You have met Return to Work Criteria. You do not have any work restrictions. Please diligently wear your PPE.
You have not met the Return to Work criteria outlined below.
Please see the specific instructions below for Known Exposures in Special Population . You are not eligible to return to your NICU, BMT unit, or Childcare Center yet. but if it has been at least 5 days, you may return to another area. Please coordinate with your manager.
Please see the specific instructions below for Known Exposures in Special Population . You are not eligible to return to your NICU, BMT unit, or Childcare Center yet. but if it has been at least 5 days, you may return to another area. Please coordinate with your manager.
No work restrictions. You may return to work immediately after testing. Hidden by Suzy 1/13/22 Return to Work Criteria for Caregivers with COVID Test Results COVID-19 Positive with symptoms Minimum 5 days from onset of symptoms AND at least 24 hours have passed since last fever without the use of fever-reducing medications, AND improvement in symptoms. COVID-19 Positive with no symptoms COVID-19 Negative with symptoms 24 hours have passed since last fever without the use of fever reducing medications, AND Improvement in symptoms COVID-19 Negative with no symptoms
Additional Guidance for BMT/NICU
Caregiver COVID-19 Positive with symptoms Minimum 10 days from onset of symptoms AND at least 24 hours have passed since last fever without the use of fever-reducing medications, AND improvement in symptoms. Caregiver COVID-19 Positive with no symptoms If there is a sick person in the household, the BMT or NICU employee will be off work until that person’s COVID results are back. If the sick household member tests positive and the caregiver cannot isolate , then the caregiver will be restricted from BMT and NICU until they have met the following criteria. The positive household member has met CDC guidelines including: 10 days since symptoms started, 24 hours without a fever without using fever reducing medications, and symptoms are improving AND AND negative rapid antigen test (day 1-2) AND negative PCR on day 5 If the sick household member tests positive and the caregiver can isolate , then the caregiver is restricted from BMT and NICU until they have met the following criteria.
Return to Work -- must complete the following COVID testing.
Negative antigen tests (days 1-2) Negative rapid PCR (day 5) If the sick household member tests negative:
The caregiver no longer has work restrictions from BMT and NICU Caregivers restricted from BMT and NICU are not restricted from working altogether. Please connect with your manager about being placed in other assignments until you are cleared to return to your usual assignment.
If you feel that your symptoms are worsening at any time, please see your primary care provider, InstaCare, or nearest Emergency Room as appropriate.
You do not need to be cleared by Employee Health before you return to work. Please follow the above guidelines or direction from your medical provider.
It is your responsibility to coordinate missed time with your manager and discuss possible telework options.
Return to Work Criteria Known Test Result Known Exposure to COVID-19 Symptomatic Return to Work Criteria No COVID Test Results for Caregivers not working in BMT or Childcare Centers Not Tested Yes - meets work-related criteria
Source has confirmed disease Source was not masked Breech in caregiver PPE Performed AGP OR 15+ minutes of cumulative close contact Yes
Developed symptoms 2-14 days after the event Testing Recommended.
Contact Employee Health for a COVID test order.
ALL Caregivers can click here to contact Employee Health with Service Now!
Canyons/Desert: Phone: 801-442-6767
Peaks: Phone 855-733-3567
Not Tested Yes - meets work-related criteria
Source has confirmed disease Source was not masked Breech in caregiver PPE Performed AGP OR 15+ minutes of close contact No.
Encourage Source Contro l i.e. wear a mask at work.
Call Employee Health for concerns about about asymptomatic disease, COVID-19 Testing can be ordered by request 2-4 days post-exposure.
Canyons/Desert: Phone: 801-442-6767
Peaks: Phone 855-733-3567
Not Tested Yes -- does not meet work-related criteria Yes Testing Recommended.
Contact your Primary Care Provider (PCP) or Connect Care for COVID Testing. Pleae check with your insurance carrier to learn if the test will be covered.
24 hours have passed since last fever without the use of fever-reducing medications,
AND
Improvement in symptoms
Not Tested No Yes Testing Recommended.
Contact your Primary Care Provider (PCP) or Connect Care for COVID Testing. Pleae check with your insurance carrier to learn if the test will be covered.
24 hours have passed since last fever without the use of fever-reducing medications,
AND
Improvement in symptoms
Not Tested Yes or No No No Work Restrictions Caregivers with COVID Test Results Waiting for PCR results No Yes Wait for your test results before returning to work Yes Yes Wait for your test results before returning to work No No work restrictions. Diligently wear PPE. Negative Yes or No
If yes, and you work in BMT or Childcare see the table below.
Yes 24 hours have passed since last fever without the use of fever-reducing medications,
AND
Improvement in symptoms
No No work restrictions. Diligently wear PPE. Positive Yes or No Yes Minimum of 5 days from onset of symptoms
AND
at least 24 hours have passed since last fever without the use of fever-reducing medications,
AND
Improvement in symptoms
You may return to work 5 days after symptom onset, but must wear a mask at work until it has been 10 days from the onset of symptoms.
No Minimum of 5 days from positive test date.
Known Exposures Special Populations (BMT, Childcare Center) Work Location: BMT, Childcare Center* Known Test Result Known COVID Exposure Symptomatic Criteria for Caregiver to Return to Work to the BMT or Childcare Center
*caregivers may work with manager to be temporarily reassigned to other departments
Not tested yet, or Negative Yes - Exposed to COVID+ person outside of household, or able to isolate from household exposure No Caregiver PCR testing a minimum of 2 days after exposure (recommended 2-4 days).
Remain off work until PCR results are back.
Contact Employee Health for COVID test order required to Return to Work.
ALL Caregivers can click here to contact Employee Health with Service Now!
Canyons/Desert: Phone: 801-442-6767
Peaks: Phone 855-733-3567
Not tested yet, or Negative Yes - Unable to isolate to exposure inside the household No The positive household member has met CDC guidelines including: 5 days since symptoms started, 24 hours without a fever without using fever-reducing medications, and symptoms are improving;
AND
Caregiver PCR testing a minimum of 2 days after household member meets above criteria.
Remain off work until PCR results are back.
Contact Employee Health for COVID test order required to Return to Work.
ALL Caregivers can click here to contact Employee Health with Service Now!
Canyons/Desert: Phone: 801-442-6767
Peaks: Phone 855-733-3567
If you feel that your symptoms are worsening at any time, please see your primary care provider, InstaCare, or nearest Emergency Room as appropriate.
You do not need to be cleared by Employee Health before you return to work. Please follow the above guidelines or direction from your medical provider.
It is your responsibility to coordinate missed time with your manager and discuss possible telework options.
If you have questions or concerns that you would like to discuss with an Employee Health Nurse, please call 801-442-6767.
Return to Work Criteria for Caregivers with COVID Test Results Known Test Result Known Exposure to COVID-19 Symptomatic Return to Work Criteria Waiting for PCR results No Yes Wait for your test results before returning to work Yes Yes Wait for your test results before returning to work No No work restrictions. Diligently wear PPE. Negative Yes or No
If yes, and you work in BMT, NICU or Childcare see the table below.
Yes 24 hours have passed since last fever without the use of fever-reducing medications,
AND
Improvement in symtpoms
No No work restrictions. Diligently wear PPE. Positive Yes or No Yes Minimum of 5 days from onset of symptoms
AND
at least 24 hours have passed since last fever without the use of fever-reducing medications,
AND
Improvement in symptoms
No Minimum of 5 days from positive test date. Caregivers working in the NICU Only Positive Yes or No Yes Minimum of 10 days from onset of symptoms
AND
at least 24 hours have passed since last fever without the use of fever-reducing medications,
AND
Improvement in symptoms
No Minimum of 10 days from positive test date.
Known Exposures Special Populations (BMT, NICU, Day Care)
Work Location: BMT, NICU, Childcare Center* Known Test Result Known COVID Exposure Symptomatic Criteria for Caregiver to Return to Work to the BMT, NICU or Day Care
*caregivers may work with manager to be temporarily reassigned to other departments
Not tested yet, or Negative Yes - Exposed to COVID+ person outside of household, or able to isolate from household exposure No Caregiver PCR testing a minimum of 2 days after exposure (recommended 2-4 days).
Remain off work until PCR results are back.
Not tested yet, or Negative Yes - Unable to isolate to exposure inside the household No The positive household member has met CDC guidelines including: 5 days since symptoms started, 24 hours without a fever without using fever-reducing medications, and symptoms are improving;
AND
Caregiver PCR testing a minimum of 2 days after household member meets above criteria.
Remain off work until PCR results are back.
If you feel that your symptoms are worsening at any time, please see your primary care provider, InstaCare, or nearest Emergency Room as appropriate.
You do not need to be cleared by Employee Health before you return to work. Please follow the above guidelines or direction from your medical provider.
It is your responsibility to coordinate missed time with your manager and discuss possible telework options .
If you have questions or concerns that you would like to discuss with an Employee Health Nurse, please call 801-442-6767.
Is someone in your household positive for COVID-19?
Yes
No
Have you had a known exposure to someone who is COVID-19+?
Yes
No
You have met Return to Work Criteria. You do not have any work restrictions. Please diligently wear your PPE. Would you like to talk to Employee Health about your specific circumstances? Hidden by Suzy 9/2/2021
Yes
No
Do you think your exposure was high risk? (i.e. prolonged amount of time, face-to-face, confined spaces)
Yes
No
I don't know
You have not met the Return to Work criteria outlined below. Would you like to talk to an Employee Health Nurse about your specific circumstances?
Hidden by Suzy 9/2/2021
Yes
No
Please do not return to work until you speak with an Employee Health Nurse to discuss your specific circumstances. HIDDEN by Suzy 6/11/2021
Call the Employee Health COVID Triage Team, AskHR 801-442-7547, 7am-8pm, 7 days week
Call the Employee Health COVID Triage Team, AskHR 801-442-7547, 7am-8pm, 7 days week
Please click
What is your best contact number?
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