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COVID-19 Self Reporting Form

Monday, March 08, 2021

Complete the form below to make a COVID-19 report to University of Arkansas - Pulaski Technical College.

*Required

*1. I am completing this form because:

If this doesn't apply to you, please type N/A in the field.

If this doesn't apply to you, please type N/A in the field.

*4. Have you been tested for COVID-19?
*5. I am a:

A mobile phone number is preferred.

13. Do you have documents from your health care provider? (Examples: COVID-19 screening test result, orders to quarantine, request to report for screening test)
14. File Upload:

If you cannot attach documents, send them to the following: Students, e-mail [email protected] Employees, e-mail [email protected]

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By submitting this form (CLICK BUTTON BELOW), I am granting permission to be contacted via e-mail or phone by a member of the UA-PTC Covid-19 Response Team concerning the information provided.