External/Escorted Visitor Request Form

A restrictive visitation policy affecting all external visitors is in place to maintain constructive operations during the COVID-19 pandemic crisis. External visitors include auditors, monitors, vendors, representatives, and others. The COVID-19 Incident Command Center will review all requests regarding access to UMMC-owned or leased property. External visitors will access areas only on a qualifying event. Complete the form below. The submitter will receive communications of the final decision.

* = Required Fields

The external visitor has previously completed the process for credentialing using the GHX Vendormate system.* Yes No
Is the external visitor going to Provide clinical, educational training? Service medical equipment? Support clinical activities in operating or invasive therapy roooms? All other scenarios which do not fall into the options provided above.
Is the external visitor providing training essential to patient care, mission completion, or hospital operations? Yes No
Name of the designated Point of Contact for this event or gathering.*
UMMC employee email address*
UMMC employee phone number*	() -
UMMC department requesting a review of the event or gathering?*
The external visitor will be meeting with the UMMC employee listed here*
UMMC IRB Number (if applicable)
Name of external visitor*
Phone number of external visitor*	() -
Name of external agency visitor represents*
What location/department/room number will the external visitor requires access?*
Start date of external visitor's stay*
End date of external visitor's stay*
Anticipated number of UMMC employees attending external visitor's event*	1 2-10 10-30 30+
External visitor expects the environment to be (check all that apply)* Clinical area for classroom training/event or information sharing Non-clinical area for classroom training/event or information sharing Clinical area for status update on essential project Non-clinical area for status update on essential project Clinical area for installation/repair/calibration Non-clinical area for installation/repair/calibration Clinical area for evaluation/review/examination/interview/audit Non-clinical area for evaluation/review/examination/interview/audit Research area for evaluation/review/examination/interview/audit Educational area for evaluation/review/examination/interview/audit Clinical area for accreditation/compliance/ program evaluation Non-clinical area for accreditation/compliance/ program evaluation Research area for accreditation/compliance/ program evaluation Educational area for accreditation/compliance/ program evaluation Clinical area for project-specific survey/interview/evaluation Non-clinical area for project-specific survey/interview/evaluation Research area for project-specific survey/interview/evaluation Educational area for project-specific survey/interview/evaluation Construction project Research site initiation visit (auditor, evaluator, inspector, a monitor) Academic visiting professor Unbelievably, the external visitor's reason to access critical areas of the hospital is not listed above
The event requires (check all that apply)* Everyone to arrive at once Individual(s) to arrive for face-to-face, one-on-one >10 employees will arrive at one time in an area <10 employees at one time in an area
The COVID-19 Incident Command Center routinely denies requests for non-essential visits outside the institution's three missions due to COVID-19-related safety precautions. Justify the request and be sure to expound upon how this request meets one of the three missions of UMMC. Explain why the visit is not virtual. Please note that historical precedence is not justification by itself for a waiver.*
The submitter verifies the provided information is complete and accurate.* Yes No
The submitter verifies the current UMMC COVID-19 Screening Protocol completion before allowing individuals into the event.* Yes No