COVID SUBMISSION FORM

1

What type of test specimen are you taking?* This field is required.Why are you taking your COVID PCR Test?

General Screening (Workplace, family, diagnostics etc.)

For outbound travel (COVID-free travel certificate)

2

Are you taking this test for travel purposes?Click 'Yes' if you require a COVID-free travel certificate

YESNO

3

Does your device have a camera?Your camera can be used to scan the Sample Specimen ID number. The Sample Specimen ID number is a barcode label found either on the sample specimen tube or in a separate sheet of 3 or 4 labels. This is the most accurate way to register your kit. If your device is unable to take a picture, please click NO and enter this manually.

YESNO

4

Sample Specimen ID NumberThe Sample Specimen ID barcode is your unique test reference and consists of 3 letters and 4 or 5 numbers (eg. ABC1234 or ABC12345). It can be found on the barcode strips or already on the sample specimen tube. Does your barcode contain 4 or 5 numbers?

45

5

Sample Specimen ID NumberThe Sample Specimen ID Number consists of 3 letters and 4 or 5 numbers (eg. ABC1234). Please scan the barcode located on the sample specimen tube via your mobile device or webcam. If you are unable to scan a barcode, please click back and select 'No'. The Sample Specimen ID number is a barcode label found either on the sample specimen tube or in a separate sheet of 3 or 4 labels. THIS IS NOT THE QR CODE - DO NOT SCAN A QR CODE OR THE TEST WILL NOT BE REGISTERED.

6

Sample Specimen ID BarcodePlease enter your unique test sample specimen ID barcode. The barcode consists of 3 letters and 4 numbers eg ABC1234. Ensure that this is correct as incorrectly entered numbers will delay sample processing. If your barcode is too long, click previous and select 5. DO NOT REMOVE DIGITS FROM THE BARCODE AS YOUR TEST WON'T BE PROCESSED.

7

Sample Specimen ID Barcode* This field is required.Please enter your unique test sample specimen ID barcode. The barcode consists of 3 letters and 4 or 5 numbers eg ABC12345. Ensure that this is correct as incorrectly entered numbers will delay sample processing.

8

Sample Date* This field is required.When will you take the sample specimen?

Date

9

Sample TimeWhat time will you take the sample on the sample date?

Hour

Minutes

10

Returns Date* This field is required.When will you be posting or dropping off the the sample specimen?

Date

11

How are you returning the sample to us?* This field is required.Where possible, we recommend returning to one of our drop box locations - see www.assuredscreening.com/returns

Royal Mail Pre-paid bag

A Courier

Drop Box Location

Other

12

Enter the Royal Mail Tracking NumberThis allows us to track your sample back into our laboratory. If using the Royal Mail pre-paid envelope, please enter the barcode number.

13

Enter the Courier Tracking Number (if known)This allows us to track your sample back into our laboratory.

14

Dropbox LocationPlease enter the location of the Dropbox used. Visit assuredscreening.com/returns for more details of our locations

Barnard Castle, County Durham (DL12 8BN)

London Kings Cross, Northdown St. (N1 9BG)

Peterborough, Cambridgeshire (PE2 6WA)

Newark-on-Trent, Nottinghamshire (NG24 2TT)

15

Name* This field is required.Please enter the name of the person taking the test.

First Name

Last Name

16

Sex* This field is required.

Male

Female

17

Address* This field is required.Please enter your address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

18

Date of Birth* This field is required.Please enter your date of Birth.

Date

19

Passport NumberSome destinations require passport number details to be listed on the COVID-free certificate. Please enter this is you would like this including, if not, leave blank.

20

Destination CountryPlease enter your destination Country if using for travel. This is used for research purposes only.

21

Email* This field is required.Please enter your email address. You will be required to verify you email address as results are send via email.

example@example.com

Confirm Email

22

Phone Number* This field is required.Please enter your phone number. We will only use this if we need to contact you about your test and are unable to get an email response.

Area Code

Phone Number

23

Are you currently displaying any COVID-19 symptoms?* This field is required.Symptoms include continuous cough, fever or loss of smell/taste. If YES, please isolate and arrange for a further diagnostic test/medical assistance via the NHS (UK) or HSE (ROI).

YESNO

24

Terms and Conditions* This field is required.Assured Screening, a trading name of Honeyman Group Ltd provides screening on a best endeavours basis. Testing provides a historic, momentary result. An individuals health status may have changed since the test was carried out. All results are based on the sample specimen provided and do not take into account any clinical assessment or patient diagnosis. It is therefore imperative to closely follow sampling instructions and ensure a good quality of specimen collection. Specimens of poor quality may fail processing or provide inconclusive results on test instruments. These will not be refunded. In such cases it is advised that the individual purchase a new test kit for a retest. Assured Screening prides itself on speedy sample turnaround and aims to provide results within 48 hours of receipt of sample specimen (or as per product turnaround aim) however is not liable in any way should testing go beyond this time for any reason. Assured Screening is not responsible for any postal delays caused by Royal Mail or other third party. It is the responsibility of the customer to ensure that the test and service is suitable to their needs. It is agreed that once this form has been submitted that the test will be non-refundable and will be processed upon receipt at the laboratory. Any false or incorrect information provided within this submission may result in a delay to issuing of results. All test results are indications and not guarantees.

25

Privacy and GDPR* This field is required.Transparency and Control are inherently our watchwords at Assured Screening, as we help assure compliance in highly regulated industries including Pharmaceutical, Healthcare and Medical. Assured Screening complies with GDPR regulations. Data is electronically stored to allow any communication necessary for the performance of a contract between our company and the individual to provide testing services. Data is stored securely and not on removable drives. Data maybe held for a period of 7 years as part of our traceable quality system. This is in the event we may need to contact you regarding your result in the future. Assured Screening minimises the number of staff with access to personal data. You agree that personal data could be shared with the following third parties as part of the COVID response or during the course of a laboratory inspection/investigation - Public Health England, National Health Service, The Department of Health and Social Care, United Kingdom Accreditation Service. If you have purchased a test through one of our clinical partners, you also agree that we can provide report your test result to them. Sample Specimens are discarded and incinerated after issuing of approved results.

26

Clinical Partner

27

Clinic/Sub-Client