COVID-19 Screening Consent Form and Authorization to Share Information for Southern Virginia University Visitors

COVID Screening Consent
This consent provides Southern Virginia University (the “University”) with your permission to perform a COVID-19 screening procedure based on the University’s need to maintain a safe environment for students, employees, and others with whom you may come into contact. By signing below, you are indicating that you voluntarily consent to this procedure for the detection of COVID-19.

The test being administered involves a nasal swab that will be tested to indicate the potential presence of COVID-19. If you decline the test, you may not be allowed to enter or remain on the Southern Virginia University campus. If you require a reasonable accommodation with respect to the test, please contact Kristie Gibbons in the Office of the President at: 540-261-4100 or at kristie.gibbons@svu.edu. You also have the right to discuss the proposed testing with your physician, to learn about the purpose, and potential risks and benefits of any testing.

This test has been approved through an Emergency Use Authorization by the FDA; however, this test alone may not be sufficient to detect or rule out the possibility that you have COVID-19. You should carefully monitor your own symptoms, notwithstanding the results of any testing.
Notice of Privacy Practices
You have received a notice of Privacy Practices, which informs you of your rights and our policies regarding HIPAA. Please read over this document and initial here that you were provided with this information.


Authorization for the Release of Medical Information
Because of the ongoing public-health crisis, it may be necessary (or legally mandated) for Southern Virginia University to share the results of your test and related identifying information with (1) public health authorities, including but not limited to the Virginia Department of Health; (2) employees within the University who have a need to know in connection with implementing the University’s safety protocols; and (3) members of the University community with whom you have been in close contact within the past 14 days. By signing below, you consent to the disclosure of such information in accordance with this authorization, and you hereby waive the right to contest disclosure or use of such information in accordance with this authorization under the Family Educational Rights to Privacy Act, HIPAA, or other applicable laws.
Personal Information




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The COVID Resource Center at Southern Virginia University is required to report gender, race, and ethnicity information to the Virginia Department of Health for any COVID-19 tests administered.
Signature
I, the undersigned patient and/or legal guardian:
  1. Consent to the performance of a COVID-19 screening procedure;
  2. Authorize the release of medical information as described above;
  3. Authorize treatment by staff at the University’s COVID Resource Center (“CRC”); and
  4. Authorize the CRC staff to contact me.
I have read, understand, and agree to all of the above.
In place of your signature, please type your full legal name below.



Required if student is under 18-years-old

Contact Information