COVID -19 SELF-REPORTING FORM

To reduce the spread of Covid-19 among the campus community, and to assure the health and safety of others, please fill out this self-report form.

Our office hours are 8am-5pm Monday-Friday.

If you are submitting this form outside our office hours, we are unable to respond until our regular business hours. You may call Student Health Services 870-575-7107 or Dean of Students 870-692-2691. If this is an emergency, please call 911.

Is this the first time you submitted this form, or is this a COVID reinfection/update?

I am completing this form because:

If you have documentation from your healthcare provider, please upload here

I am :

My First Name

My Last Name

What is your Date of Birth

(MM-DD-YYYY)

Race/Ehnicity :

My Phone number

(###-###-####)

My UAPB Email Address:

My Campus ID#

Do you live on campus :

Have you been vaccinated for COVID-19 :

Have many doses?

Do you have any additional information you would like to report?

By submitting this form, I am granting permission to be contacted via email or phone by a member of the UAPB Student Health Services staff and/or Dean of Students concerning the information provided.

After submitting this form, you should receive an email response or call with instructions and information. Please read the response and follow the instructions. If you do not receive a response within 24 hours, please call Student Health Services @ 870-575-7106,

Dean Owens @ 870-692-2691, Director Of Counseling and Student Wellness, @ 870-575-8291.

I acknowledge

Yes

Contact Information