**PLEASE NOTE THAT YOU MAY NOT EAT, DRINK, SMOKE, OR BRUSH 30 MINUTES PRIOR TO YOUR SALIVA COLLECTION *** FREE COVID-19 Saliva Specimen Test Screening in Collaboration with WSU
NOTICE AND AUTHORIZATION FOR COVID-19 TESTING AND RELEASE OF INFORMATION: In response to the COVID-19 worldwide pandemic and national emergency, the Wichita State University Molecular Diagnostic Laboratory (“MDL”) has implemented policies and procedures based on current recommendations from the Centers for Disease Control and Prevention (“CDC”) and other state and local public health authorities to ensure the safety of the community. As part of these measures, we ask that you consent and authorize MDL to process a COVID-19 diagnostic test as set forth below. What are the possible risks and benefits of the test? As with any test, there is a potential for a false positive or false negative result. As such, the test result should not be interpreted as a clinical diagnosis of COVID-19 infection. MDL is not acting as your healthcare provider to provide medical services. A diagnosis can only be made by your healthcare provider after all clinical and laboratory findings are evaluated. What will you do with my test results? MDL is asking you to authorize the handling of your test results as follows:• If you agree to it, this authorization will remain in effect until the earlier of: (a) a declaration that the COVID-19worldwide pandemic and national emergency is over; or (b) twelve (12) months from the date of specimen collection.• While this authorization is in effect, MDL may access, disclose and use your COVID-19 test result to your healthcare provider, your employer, school, or any other third party requesting that you take this COVID-19 test, and, to the extent required by law, applicable federal, state, or local governmental entities in order to monitor for COVID-19 and promote the health and safety of the community. Please note that any redisclosure of your COVID-19 test result may no longer be protected by federal and state privacy laws. How will my test results be reported? If you’ve agreed to the terms and conditions, your test results will be sent to you through SoftGenePortal from SCC Soft Computer®. Otherwise, your results will be reported to you by your health careprovider that ordered the COVID-19 test. What should I do if I am injured? Due to the coronavirus emergency, the federal government issued an order that may limit your right to sue if you are injured or harmed while participating in testing. If the order applies, it limits your right to sue researchers, healthcare providers, any manufacturer, distributor, including Wichita State University. However, the federal government has a program that may provide compensation to you or your family if you experience serious physical injuries or death. To find out more about this “Countermeasures Injury Compensation Program,” please visithttps://www.hrsa.gov/cicp.• You agree to allow Wichita State University to process your COVID-19 test.• You have been provided this informed consent to read.• You have verbally consented to the terms in this informed consent and agree to allow your healthcare provider or another person overseeing the sample collection to record your acknowledgement of this informed consent.• You acknowledge that you have been informed about the testing process and its possible risks and benefits.• You also acknowledge that you have been given the opportunity to ask questions before testing and have had them answered to your satisfaction. Your completion of this form and signature serves as an electronic agreement and consent.
Full Legal Name
4 digit PIN Number for Results
Address (PO Box is not acceptable, must have a physical address)
Street Address Line 2
State / Province
Postal / Zip Code
County of Residence (SG, KM, RN, BU, HV, etc)
Cell Phone Number
Date of Birth
Ethnicity (this information is used to report testing statistics)
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Primary Care Provider (Doctor)
Primary Care Provider (Doctor) Location Address, City/State
Check any of the following symptoms you are currently experiencing:
Shortness of breath or difficulty breathing
Fever or Chills
Muscle or Body Aches
New Loss of Taste or Smell
Nausea or Vomiting
Congestion or Runny Nose
No Symptoms, but contact for 15 mins or more within 6 ft of a documented SARS-CoV-2 infection
Symptoms above and a confirmed contact with a confirmed case of COVID-19.
Date of Symptom Onset or Suspected Contact
Please list the name of anyone who has helped you complete this form:
**YOU UNDERSTAND THAT YOU MAY NOT EAT, DRINK, SMOKE, OR BRUSH YOUR TEETH 30 MINTUES PRIOR TO COLLECTION OF YOUR SALIVA. By signing below, you agree to the release and consent listed at the top of this form.
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm