COVID Testing Consent and Release - Asymptomatic Testing

Name *

First Name Last Name

I am: *

SUU Employee SUU Student - enrolled Spring 2021 Visitor (Immediate family of SUU employee or student) Local First Responder

T-Number *

Walk-in?

Yes No

Schedule an Appointment *

You may need to update the timezone above to America/Denver (GMT-07:00)

Street Address *

Unit Number

City *

State *

Zip Code *

Phone Number *

The results of your test will be emailed to you. Please provide us with a valid email address.

Email *

example@example.com

Date of Birth *

Date

Birth Sex *

Ethnicity *

Race *

Please carefully read and sign the following Informed Consent and Release:

I authorize Southern Utah University (“SUU”) to conduct collection and screening for COVID-19.
I understand, as required by law, my test results will be disclosed to the county, state, or to other governmental entities. I agree that my test results and other related information may be disclosed to those entities or those within SUU deemed to have a need to know in order to take steps to mitigate the spread of COVID-19, including in order to conduct contact tracing. I understand SUU will not disclose my identity unless necessary to allow individuals to take appropriate action to protect the health and safety of others or disclosure is made in accordance with applicable privacy laws. I agree to allow SUU to use the email I have provided or SUU email to communicate my information regarding testing.
I understand that SUU is not acting as my medical provider, this screening does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regard to my screening results. Screening results are preliminary only for use by SUU for monitoring and to assist in contact tracing and other mitigation efforts and are not performed to determine final diagnosis or treatment. I agree I it is my responsibility to seek medical advice, care, and treatment from my medical provider, contact my medical provider if I have questions or concerns, and seek emergency medical care if my condition is severe or worsens.
I consent and give my permission for the COVID-19 screen using SUU facilities. I understand that sample collection is self-administered, agree to self-administration, and accept any risks associated with testing, including self-administration.
I understand that, as with any medical screen, there is the potential for a false positive or false negative COVID-19 result.
By submitting this form, I agree to the above. I also agree that I have been informed about the screening purpose, procedures, possible benefits, and risks. To receive a copy of this informed consent, or ask any additional questions, please contact Mindy Benson or Mike Humes.

** I understand that if I am a minor, my parent or legal guardian must give also consent on my behalf, and I and my parent or guardian agree to the above.

Can we send you text messages? *

Yes No

Signature: *

Or Parent Signature if participant is under the age of 18 Clear

Print Name: *

Date *

Date

Asymptomatic COVID Testing Consent and Release

Contact Information