INFORMED CONSENT FOR COVID-19 DIAGNOSTIC TESTING

Authorization and Consent for COVID-19 Diagnostic Testing

I voluntarily consent and authorize Worksite Labs, Inc. ("WSL"), a clinical laboratory certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) to provide COVID-19 diagnostic testing services. I understand that this COVID-19 test, and is conducted solely for the purpose of an athletic team participation event, and is not performed for any other medical purpose. I acknowledge that neither Hillside Memorial nor WSL are providing any form of medical treatment related to COVID-19, and that I am solely responsible for seeking appropriate medical attention as may be indicated by the test

By signing or clicking on ACKNOWLEDGEMENT below, I hereby give my consent and authorize WSL to collect my sample using a nasopharyngeal swab, oral swab, or other recommended collection procedures, in conformity with Hillside Memorial Park and Mortuary testing protocols, and to process and analyze my sample solely for the detection of the COVID-19 virus. WSL will report my test result to Hillside Representatives, and, to public health authorities as may be required by law. The Hillside Representatives that will have access to my results are: Ellie Buckland- Director of Human Resources and Alexandra De La Garza-Business Operations Manager. I understand that there are risks to the collection procedure, such as nosebleed or nasal passage soreness. The testing process may be unpleasant and uncomfortable. I also understand that it is possible for testing results to provide false negative or false positive infection information, and that I may contract the virus after having a negative test result (or contract the virus immediately prior to the test, which may not detect the COVID-19 virus I understand that there are asymptomatic carriers of the COVID-19 virus, so I may exhibit no symptoms yet test positive for COVID-19. I understand that I may obtain COVID-19 testing from another laboratory or healthcare provider and that I am not required to obtain a COVID-19 test from WSL for the purpose of Hillside Memorial participation requirements.

I further understand and agree to the following: WSL will provide a state-licensed healthcare provider who will supervise the collection of my specimen or collect my specimen for COVID-19 testing. I hereby authorize WSL to perform testing on my specimen for the COVID-19 virus only. The exact test method used for COVID-19 testing may vary from time to time and may include a nasopharyngeal swab or another method. I understand and accept that I may experience some discomfort associated with sample collection using a swab. By giving my authorization and consent to be tested by WSL, I understand that WSL will only administer a one-time COVID-19 test for the purposes of Hillside Memorial participation requirements and WSL will not provide any other healthcare or medical services or any medical advice to me or other colleagues. If I have a medical question, if my condition worsens, or if I test positive for COVID-19, I agree to consult with my personal healthcare provider. I assume complete and full responsibility for all the actions I take with regards to my test result.

Iunderstand that the COVID-19 testing performed by WSL is not done for any other medical purpose other than to test for the COVID-19 virus, and neither the test results nor any information provided to me by WSL constitutes any form of medical advice. I understand and agree to not use or rely upon the COVID-19 testing provided by WSL for any medical 

healthcare decision without first consulting with a licensed professional healthcare provider who is authorized to provide me healthcare services. As with any laboratory testing, I understand and accept that there is a risk of receiving a false positive, false negative, or inconclusive test result, which may impact my ability to participate in athletics and have other impacts (including potential quarantine or other public health requirements If I test positive for COVID-19, I understand that I will be solely responsible for all medical expenses associated with any medical treatment and other healthcare services, including any confirmatory COVID-19 testing. If my test result is positive, I agree to consult with a licensed professional healthcare provider or other equivalent medical professional for further testing and/or treatment and will take fully responsibility for my actions thereafter, including complying with my medical professional's advice and CDC guidelines. I understand and accept that under certain circumstances, and related to public health regulations, WSL may be required by law to report my test result to certain state and local public

While WSL will take reasonable measures to protect the confidentiality of my test result, I understand that any disclosure of information carries with it the potential for redisclosure, and once disclosed, the information I provide to WSL, including my test result, may not be protected by federal, state, or other applicable medical information privacy laws.

1. Testing Rights and Privacy Practices a) Notice of Privacy Practices and Patient Rights: WSL's Notice of Privacy Practices describes how it may use and disclose my protected health information in order to provide COVID-19 testing services, including sample collection, billing, and reporting test results, as permitted or required by law. To review a copy of my rights as a customer and WSL's Notice of Privacy Practices, please click the "Privacy Policy" link at the bottom ofthe page. I acknowledge that Worksite Labs has provided me with a copy of Worksite Labs' Notice of Privacy Practices. b) Disclosure to Government Authorities: I acknowledge and agree that WSL may be required by law to disclose my test results and related information to the appropriate federal, state, or local governmental and regulatory entities or public health authorities.

To the fullest extent permitted by law, I hereby release, discharge and hold harmless WSL, including, without limitation, any each respective WSL officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, directly arising out of or in connection with any act or omission relating to my COVID-19 test or the disclosure of my COVID-19 test results.

I understand that I may revoke this authorization at any time in writing by email to

support@worksitelabs.con except to the extent that action has been taken in reliance on this authorization.

This consent will be effective immediately once I select ACKNOWLEDGEMENT or sign. I understand that I have a right to receive a copy of this authorization at the email address I provided. I understand that if I use WSL for any future COVID-19 testing associated with athletic team participation in the future, I may be required to sign a new consent and authorization form

By selecting the ACKNOWLEDGEMENT during the registration process for COVID-19 Testing at WSL, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 test, procedures to be performed, potential risks, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 test and I understand that if I do not wish to continue with the sample collection, testing, or analysis of my sample, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo testing for COVID-19 with WSL.