Who Should Complete This Form?

In partnership with NYIT College of Osteopathic Medicine at A-State, Arkansas State has implemented a COVID-19 Self-Reporting Form for the A-State faculty, staff and students. The form is to be submitted by an individual when:

• You have been tested for COVID-19
• You have been instructed to self-quarantine for suspected COVID-19 infection
• You have received a positive COVID-19 test result

Do not use the COVID-19 Self-Report form for:

• Reporting your concern or knowledge of others COVID-19 condition. The form is only for individuals to report their own health conditions.
• Asking for academic assistance related to your COVID-19 status.

If you have questions like these, or other general concerns related to COVID-19, remember to use Pack Support.

We are also asking all students, faculty, and staff to submit the COVID-19 Self-Reporting form if they have met ANY of the following:

• Are experiencing symptoms of COVID-19 (fever, cough, shortness of breath, weakness, fatigue, nausea, change in taste or smell)
• Been in close contact with a COVID-19 positive individual.

Students, staff or faculty with COVID-19 may have a wide array of symptoms ranging from mild symptoms to severe illness. A comprehensive list of COVID-19 symptoms can be found on the CDC website.

What does this form do?

This form is how you will notify Human Resources, the A-State health team, and other appropriate members of the A-State COVID-19 response team about your condition. It will create an email confirmation of the report for illness/exposure/monitoring, help reduce exposure to the campus community, and allow the university to track the ill students and/or employees and provide needed services and follow-up care. This form does not take the place of the daily employee health screening in the my.AState portal.

What Happens Next?

Students and employees completing the self-reporting form will be contacted by a member of the A-State health team. If you are experiencing symptoms of COVID-19, or a member of the health team deems it necessary, you will then be directed to the NYIT Medical Clinic for further evaluation and testing. The self-reporting form is secure, and all information will maintain confidentiality.

Questions?

If you have any questions or concerns or do not have access to a computer to complete the self-reporting form, please call our NYIT Medical Clinic at 870-972-2054.