Consent to Be Tested and Authorization to Share Information
COVID-19 is an infectious illness caused by a coronavirus. George Mason University is providing my minor child with the opportunity to get tested for COVID-19 so my child may meet the requirements to participate in the summer camp program.
I consent and authorize George Mason University (GMU) to conduct collection, testing and analysis of samples from my child for the purpose of a Center for Disease Control (CDC), Food and Drug Administration (FDA), Emergency Use Authorization (EUA), or CAP/CLIA approved Coronavirus (COVID-19) test. Analysis of the samples may be conducted in partnership with a third-party laboratory and/or possibly tested for variants if indicated. I acknowledge that I am giving this consent for my child to be tested voluntarily and that any testing done on my child is voluntary. I understand that my child may carry or transmit COVID-19, even if he/she does not have symptoms. I have been informed about the test purpose and procedures.
I understand possible risks include:
- Discomfort or other complications that can happen during sample collection.
- Potential incorrect test result. I understand that, as with any medical test, there is the potential for a false positive result (when the test indicates my child has the virus, but my child does not) or false negative result (when the test indicates my child does not have the virus, but my child does).
I understand potential benefits include:
- The results, along with other information, can help me make informed decisions about my child’s care.
- The results of this test may help limit the spread of COVID-19 to others in my community.
I understand George Mason University is not acting as my child’s medical provider. This testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action with regards to my child’s test results.
I understand that my child’s test results will be treated as confidential medical records. If my child’s test results in a positive or suspected positive diagnosis of COVID-19:
- GMU must disclose any positive or suspected positive test results, together with my child’s contact information to the Virginia Department of Health (VDH) or other county, state, or governing public health entity as required by law.
- I will cooperate fully and immediately with VDH in its contact tracing efforts by providing the names and contact information of any and all people with whom my child has come into close contact as well as recent locations my child has visited.
- George Mason University may provide this information to the applicable Student Health Services, Housing and Residence Life, Camp Administrator or Safety, Emergency, and Enterprise Risk Management employees so that they may contact me for follow up actions and for purposes of cleaning and sanitizing. I understand that my child’s identifiable protected health information will not be released for any other purpose without my written and specific consent.
I understand this authorization is in effect until both the Federal Public Health Emergency declaration and the Virginia State of Emergency are revoked. I also understand that I may revoke or cancel this authorization at any time by submitting a written statement to firstname.lastname@example.org except to the extent that action has already been taken based on this authorization.
I agree to receive this form electronically and provide my authorization by electronic signature. I acknowledge that I am capable of saving, printing or otherwise retaining this form if I wish to do so.
I am eighteen (18) years of age or older.