COVID-19 Self Report 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.
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. 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.
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.