City of Stamford Employee Consent to SARS-CoV-2 Testing

Consent

Your employer, the City of Stamford (“Employer”) has hired Progressive Diagnostics, LLC (“Progressive”), to provide SARS-CoV-2 testing to its employees. This form explains the SARS-CoV-2 test and who will get your results.

1. The test that you will receive is designed to detect if you have SARS-CoV-2, also known as the “coronavirus.” SARS-CoV-2 is the virus that causes the disease known as COVID-19. The results of this test will not tell you if you had the virus in the past or if you have immunity to getting the virus in the future. It only tests for the presence of the virus in your specimen at the time of the test.
2. Your specimen will be collected through a process that involves swabbing your nose.
3. Your results will be shared with your Employer who will provide your test results to you. Your results also may be shared with the Connecticut Department of Public Health and certain federal, state, or local government agencies as required by law.
4. By signing this form, you authorize Progressive to release the results of your test to your Employer for the purpose of managing their SARS-Co V-2 safety program. By signing this form, you also indicate that you understand the following: (i) that you may revoke this authorization at any time by notifying your Employer’s Director of Human Resources, in writing, and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it; (ii) this authorization will expire two (2) years after the date on which it is signed.
5. If your results are positive, please contact a doctor immediately. Only a doctor can diagnose you with COVID-19 and give you information about what you should do next. It is possible for the test to produce an incorrect negative result (called a “false negative”) in some people who have SARS-CoV-2. If you test negative but have symptoms of COVID-19 or concerns about exposure to SARS-CoV-2, contact a doctor to determine if you should be retested or take other actions.
6. You should talk to a doctor about any health care needs you may have, including any related to receiving this test. Neither Progressive nor your Employer is responsible for any medical care you receive.
7. Progressive is providing this testing as a service to your Employer and Progressive is not responsible for the ways in which your Employer may use the results of your test. If you have questions about why you are taking this test or how your Employer may use the results of your test, please talk to your Employer.
8. If there is leftover specimen after your test is performed, Progressive may remove information that identifies you from the specimen and use it for quality assurance, validation and laboratory testing development.
9. By signing this form you agree: (i) that you have read and understand the information in this consent form; (ii) to provide a nasal swab specimen for testing; (iii) to have your specimen tested by Progressive for SARS-CoV-2; and (iv) that your leftover specimen and/or information about you may be used without information that identifies you after the testing is over for analysis. You voluntarily agree to this testing for SARS-CoV-2.