COVID-19 Self Reporting Form

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:

I have been tested for COVID-19.

I tested positive for COVID-19.

I have been in direct contact with a COVID-19 positive person.

I have symptoms of COVID-19.

I have a household member who tested positive.

I have a household member who is ill.

My children have been quarantined/exposed to COVID-19.

*2. If you have been in direct contact with a COVID-19 positive person, when was the estimated date of exposure?

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

*3. If you have symptoms of COVID-19, when did you develop noticeable symptoms?

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

*4. Have you been tested for COVID-19?

Yes

*5. I am a:

Student

Faculty

Staff

*6. What was your last day on campus?

*7. First Name:

*8. Last Name:

*9. My Student/Employee ID Number:

*10. My Date of Birth:

*11. My E-mail:

*12. My Phone Number:

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)

Yes

14. File Upload: (If you cannot attach documents, send them to the following: Students, e-mail [email protected] Employees, e-mail [email protected])

Add another

15. Do you have any additional information about your report?

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.

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COVID-19 Self Reporting Form