• COVID-19 Screening Participant Information & Consent Form

  • Participant Information

  • Participant Contact Information

  • Participant Consent for Testing

  • COVID-19 RT-PCR Testing will be performed by a laboratory certified under the Clinical Laboratory Improvement Amendments (CLIA) to perform high-complexity testing and is performed in accordance with the Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency.

    This testing is intended for screening of asymptomatic persons with no known close contact exposure to COVID-19 and does not require a physician order to perform.

    • Informed Consent for Testing:
    • I understand my results are NOT for Diagnostic Use. The results are intended for information use for the purpose of detecting transmission risks and hot spots.
    • I understand that, as with any medical test, there is the potential for false positive or false negative test results to occur.
    • I acknowledge that a positive test result is an indication that I should follow Centers for Disease Control (CDC) guidelines and may need to self-isolate to avoid infecting others.
    • I authorize my test results and demographic information to be disclosed to the organization facilitating my participation in this COVID-19 screening as well as to the county, state, or any other governmental entity as may be required by law.
    • I understand that I am not creating a patient relationship with the testing facility and that testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action including seeking medical advice, care, and treatment from my medical provider if I have questions about my test results.
    • I understand that if I am an age eligible to donate plasma and my results are positive for COVID-19, I give my authorization to be contacted for a referral to donate COVID-19 Convalescent Plasma.
    • I acknowledge my test result report will include further information on the test results interpretation in accordance disclosures required by the Food and Drug Administration (FDA
    • I acknowledge that by signing, I am not exhibiting any of the following symptoms: New loss of taste or smell, fever, chills, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.

    I authorize the collection of a nasal swab sample for use in COVID-19 RT-PCR testing by the above referenced laboratory.

    I, the undersigned, voluntarily agree to this testing for COVID-19 and understand this consent will remain on file and in effect for subsequent periodic screening tests until I withdrawal this consent, or this consent is superseded by a new consent. I also consent the laboratory to contacting my by phone to discuss my results directly with me, if necessary.

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  • Parental Consent (for participants under 18 years of age)

    I agree that the person named above will receive the tests indicated to screen for COVID-19. I have had a chance to ask questions about the

    sample collections process. I affirm that I am an adult who can legally consent for the person named above to get screened for COVID-19. I freely

    and voluntarily give my signed permission for these screening tests to be given.

    I authorize the release of information to the organization facilitating the COVID-19 testing as well as county, state, or any other governmental

    entity as may be required by law, as well as the San Antonio Metropolitan Health District.

  • I, agree to this testing for COVID-19 and understand this consent will remain on file and in effect for subsequent periodic screening tests until I

    withdrawal this consent, or this consent is superseded by a new consent.

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