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COVID-19 is an infectious illness caused by a newly discovered coronavirus. George Mason University is providing me with the voluntary opportunity to get tested for COVID-19.
I consent and authorize George Mason University (GMU) to conduct collection, testing and analysis of samples from me for the purpose of a Center for Disease Control (CDC) and/or Food and Drug Administration (FDA) approved Coronavirus (COVID-19) test. Analysis of the samples will be conducted in partnership with a third-party laboratory. If I undergo testing, I acknowledge that I did so voluntarily. I understand that I may carry or transmit COVID-19, even if I do not have symptoms. I have been informed about the test purpose and procedures.
I understand possible risks include:
I understand potential benefits include:
I understand George Mason University is not acting as my medical provider unless as a student, I request Student Health Services to be my provider. This testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results.
I understand that my test results will be treated as confidential medical records. If my test results in a positive or suspected positive diagnosis of COVID-19:
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.
After selecting submit below, you will be redirected to a online scheduling system to set up an appointment.
If you are symptomatic for COVID-19, are currently in quarantine or isolation, are under 18 years old, or have tested positive in the last 3 months, you qualify for an exemption from this testing requirement. If you meet these criteria, or you are currently a residential student who is not currently living on campus, you may apply for an exemption using the following form. If your exemption is approved, you will not be required to complete this test. If your exemption was related to your housing status, Housing and Residence Life also will deactivate your room card access.
We appreciate your support in continuing to ensure we maintain a safe environment for all students, faculty, and staff on campus. If you have any questions regarding this testing process, please contact email@example.com. If you have symptoms, do not complete testing through this process, and instead please contact Student Health Services at 703-993-2831 for evaluation and testing.
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