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CONSENT FOR TESTING AND DISCLOSURE OF INFORMATION

CONSENT FOR TESTING AND DISCLOSURE OF INFORMATION FORM

 

Consent is granted by you to Colby College and its designated medical providers (collectively, “Colby”), Clinical Research Sequencing Platform, LLC and its affiliate, The Broad Institute, Inc. (collectively, “CRSP”), Abbott Rapid Dx North America, LLC, and any other testing providers designated by Colby for the COVID-19 testing and related disclosures outlined below in support of Colby’s on-campus programming and operations in response to the COVID-19 pandemic.  (CRSP and any other testing providers designated by Colby are collectively referred to as “Testing Provider”.)

 

The testing that you are consenting to is designed to detect if you have SARS-CoV-2, also known as the “coronavirus.”  (This testing is hereinafter referred to as the “testing” or “test”.)  SARS-CoV-2 is the virus that causes the disease known as COVID-19.  The results of this testing 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.  For more information on COVID-19 testing, please see the Centers for Disease Control and Prevention’s COVID-19 Testing Overview.

 

In instances where the testing analysis must be performed by a Testing Provider at a clinical laboratory, your testing specimen and information will be released to Testing Provider for the purpose of analyzing the testing specimen. In instances where the testing analysis is performed by Colby, the specimen will be provided to Colby for such analysis. There are also forms of testing which can be self-administered and analyzed.  The results of the testing analysis, whether performed by you, Colby or a Testing Provider, shall be supplied to you and Colby, and where required by law, to certain federal, state, or local government agencies, as set forth below.  

 

CRSP is a clinical laboratory. Colby may engage other clinical laboratories depending on the Testing Provider it is using at the time. Testing Provider does not give medical advice or provide medical care.  You should talk to a healthcare provider about any healthcare needs you may have, including any related to receiving this test.  Testing Provider is not responsible for any medical care you receive. Testing Provider is providing this testing as a service to Colby, and Testing Provider is not responsible for the ways in which Colby may use the results of your test.  If you have questions about why you are taking this test or how Colby may use the results of your test, please talk to a Colby healthcare provider. If there is leftover specimen after your test is performed, Testing Provider may remove information that identifies you from the specimen and use it for its quality assurance, validation and laboratory testing development either alone or in collaboration with a public health authority.    

 

If you are a student at Colby, your rights concerning the records discussed in this consent are governed by the Family Educational Rights and Privacy Act and its implementing regulations (collectively, “FERPA”).

 

Specifically, in signing this consent and disclosure of information, you authorize Colby and Testing Provider to undertake, and you are consenting to the following:  

 

  1. The administration of your testing for the COVID-19 virus by Testing Provider and/or Colby (depending on the nature of the test) in concert with Colby’s COVID-19 testing protocols, as may be amended from time to time; and 
  2. The disclosure of your personal identifiable information, including name and date of birth, and your test results to/from Colby and Testing Provider, and Testing Provider’s contractors who assist in the performance and analysis of the testing; and
  3. Authorization to Testing Provider to use your leftover testing sample and information on a de-identified basis for analysis in collaboration with public health authorities, as well as quality assurance, validation and laboratory testing development; and 
  4. The disclosure of your testing results and relevant health information as necessary to Colby healthcare providers who ordered your test, Colby personnel supporting Colby’s on-campus programming and operations in response to the COVID-19 pandemic, including implementation of contact tracing and other infection control and mitigation measures by Colby and other parties as required by law; and
  5. Disclosure of your test results and relevant health information for treatment purposes, notification, and/or coordination of care with your healthcare providers; and 
  6. Utilization of CoVerified, a mobile application to facilitate the scheduling of testing, communication of testing results, symptom management, contact tracing, vaccination status and verification, and other tools in support of Colby’s COVID-19 response plan, and disclosure of your personally identifiable information and testing results as necessary to CoVerified, or any other application utilized by Colby for such purposes. 
  7. This consent expressly prohibits Testing Provider and Colby from conducting DNA testing on your testing samples; and
  8. This consent permits Testing Provider and Colby to supply your testing data to the Colby COVID-19 response team to address the presence of the virus and to monitor the public health environment at the College.  It also permits disclosure of your data to federal, state or local public health authorities. As required by law, Colby and/or Testing Provider must disclose your testing results to public health departments, including the Maine Center for Disease Control and Prevention.  When making such a disclosure to the Maine Center for Disease Control and Prevention, Colby and Testing Provider are required to provide your identifiable information, including your name, date of birth, race, ethnicity, sex, residence address, phone number, Colby e-mail address, provider information, and diagnostic laboratory findings. You are not providing consent for the use of your data for research requiring Colby Institutional Review Board (IRB) approval.

 

In signing this consent and disclosure, you acknowledge that:

 

  1. COVID-19 testing services provided by Colby and Testing Provider are provided at no cost to you.  However, (i) you are financially responsible for paying all costs associated with the healthcare services you receive as a result of such testing; (ii) you may be financially responsible for such costs even if you have health insurance, depending on the benefits and coverage limitations of your health insurance policy; and (iii) you are financially responsible for charges not covered by your health insurance, including deductibles and co-payments.
  2. This authorization will expire twelve (12) months from the date hereof, unless revoked in writing earlier.  
  3. If you choose to revoke this consent, you must send your revocation notice to covid-19@colby.edu.  You understand that revocation of this authorization will limit your ability to participate in Colby programming and operations.
  4. You are not required to sign this consent; however, if you do not consent, neither Colby nor Testing Provider will be able to perform testing on you, which likewise will limit your ability to participate in Colby programming or operations.

 

By signing below or signing electronically, you acknowledge that you have read the above information, understand and agree to the above statements, and have been given the opportunity to have any questions you might have answered.

 

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Signature Date
 
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Printed Name
 
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Parent/Guardian if student is under age 18     Date
 
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Printed Name

 

07/30/2021