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COVID-19 Self Reporting

COVID-19 Self Report Form

A thumbnail of the formIn 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.

Submit this form if...

The form is to be submitted by an individual when:

  • You have been tested for COVID-19 due to potential symptoms or exposure
  • You have been instructed to self-quarantine for suspected COVID-19 infection
  • You have received a positive COVID-19 test result
  • You have been in close contact with a COVID-19 positive individual
  • You are experiencing symptoms of COVID-19 

Do NOT submit this form if...

Do not use the COVID-19 Self-Report to report a test taken for screening purposes (medical procedures, travel, etc.).

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

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.

What Happens Next?

Students and employees completing the self-reporting form will be contacted by a member of the A-State health team. The self-reporting form is secure, and all information will maintain confidentiality.


If you have any questions or concerns or do not have access to a computer to complete the self-reporting form, please contact our A-State Medical Emergency Response Team (MERT@AState.edu) via email.