TEST Fluidigm Patient Info Consent Confirmation

CONSENT TO BE TESTED AND AUTHORIZATION TO SHARE INFORMATION

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:

• 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 I have the virus, but I do not) or false negative result (when the test indicates I do not have the virus, but I do).

I understand potential benefits include:

• The results, along with other information, can help me make informed decisions about my 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 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:

• GMU must disclose any positive or suspected positive test results, together with my 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 I have come into close contact as well as recent locations I have visited.
• George Mason University may provide this information to the applicable Student Health Services, Human Resources, 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. If I live in GMU housing, I authorize my name and positive COVID-19 test result or contact status to be disclosed to Housing and Residence Life for the purposes of providing appropriate cleaning and sanitizing, and assignment of isolation and/or quarantine housing. If I am a student-athlete, I authorize my name and positive COVID-19 test or contact status result to be disclosed to GMU Intercollegiate Athletics. I understand that my 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 safety@gmu.edu 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.