RapiFast®

COVID-19 Employee Testing Consent Form

I authorize specimen collection with a nasopharyngeal swab and/or collection of blood through venipuncture for SARS-CoV2, the virus that causes COVID-19. I further understand, agree, certify, and authorize the following:

  1. I understand that my employer (as stated in the form below), has contracted with RapiFast® for collection of my specimen. I authorize RapiFast to collect the specimen.
  2. I have the right to refuse testing. 
  3. This test involves a swab (like a Q-Tip, but smaller) slid into the nostril to obtain a sample from the back of the top of the throat called the Nasopharynx.  It may be uncomfortable, painful, or potentially cause mild abrasion or bleeding.  No long-lasting side effects from testing are expected. I understand that there is minimal risk with collection of a specimen with a nasal swab.  I acknowledge that the nature of the collection will cause slight discomfort.
  4. I understand that Risks and Complications of the blood draw include: Pain on the draw entry, bruising, I may become lightheaded, inflammation of the vein and rare risk of infection.
  5. My employer has contracted with RapiFast® for laboratory analysis and report of my specimen. I authorize RapiFast® to perform testing on my specimen.
  6. I understand that processing of the specimen and results, depending on type of test, may take 15 minutes (Rapid Test) or between 24/48 hours (PCR).
  7. RapiFast® will provide test results to my employer who contracted for the testing.  I authorize Eurofins Viracor, Inc. to release test results or other information necessary to my employer, RapiFast®, and to me.
  8. I have received the “Fact Sheet for Patients regarding the Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Tests”, as required by FDA. (Read here)
  9. I understand that RapiFast® has infectious disease reporting responsibilities under applicable governmental regulations and will report my testing information in accordance with these regulations.
  10. I understand that my results will be used as a part of RapiFast® (see protocol in Appendix 1) and agree to participate and provide information as requested.
  11. I understand that I am not entering into a doctor-patient relationship with RapiFast® or my employer and that any questions or required follow up shall be my responsibility to arrange with my own physician.

For employer yo keep:

  • An opportunity to ask questions about the above information and consent has been given to me.  
  • My questions have been answered to my satisfaction.
  • I understand I have the right to refuse testing.
  • I understand my signature represents consent to testing and results being received by RapiFast® and my employer.
  • I understand that, if positive, I will be required to stay home. I will need to isolate/quarantine myself from all people (including those I live with, if at all possible) for at least 14 days. I will not be able to return to work unless all of the following have occurred: (1) Two negative tests in a row, at least 24 hours apart; (2) I am not experiencing a fever (without the use of fever-reducing medicines); and (3) Any other respiratory symptoms I am experiencing (for example, cough or shortness of breath) have improved. 

 

By signing below, I acknowledge that I have read, understand, agree, certify, and/or authorize the information above and further agree that I and my heirs, executors and assigns hereby release my employer, Eurofins Viracor, Inc., and RapiFast®, including its employees, agents, and contractors from any and all liability and claims.

 

You will receive an e-mail with your consent form attached and useful information by the CDC (Centers for Disease Control and Prevention). If you have not received the e-mail within 10 minutes, please check your spam folder on your mailbox. If you see any errors on the form, please contact RapiFast® as soon as possible.

    Date of Birth*

    Phone Number*

    Testing Date*

    Do i agree to be tested?*

    Legal Guardian (complete only if employee is under the age of 18)

    Signature* (use your finger (if you are on a touch-screen) device or mouse to sign into the blank space):