Purpose: To consent to taking a COVID-19 viral test during the week of 04/14/2021 and provide results of said test to the City of Carson.

I am an employee of the City of Carson in the following position and department, and I declare as follows, by electronically signing this affidavit:

1. I agree to submit to a COVID-19 viral test approved or authorized by the U.S. Food and Drug Administration (FDA) to diagnose a current infection of SARS-CoV-2, the virus that causes COVID-19. Currently, City of Carson is offering a self-administered, easier-to-use nasal swab test provided by US Health ( at the facilities of City of Carson located at City of Carson
Community Center at 801 E. Carson Street, Carson, CA 90745.

2. I agree to submit the test results or authorize the release of the test results to the City of Carson.

3. I understand that the results from the test will help identify employees who may have COVID-19 and isolate those employees who test positive, in order to minimize the transmission of COVID-19 in the workplace.

4. I understand that the Americans with Disabilities Act, the Family and Medical Leave Act, the California Confidentiality of Medical Information Act, and other privacy laws prohibit the City of Carson from disclosing my medical/health information, including the test results, to unauthorized individuals. I understand that the City of Carson will take reasonable measures to keep my name and identity confidential to the greatest extent possible in accordance with applicable law.

5. I understand that all employees who are required to report to work, either in person or remotely, as of the date of the signing of this form must submit to the test, and must provide a test result to the City of Carson. I also understand that, absent extenuating circumstances or required accommodations in accordance with applicable law, failure to submit to the test may prevent me from returning to the workplace or from working remotely for the City of Carson, and may subject me to discipline, up to and including termination.

6. I understand that the Los Angeles County Department of Public Health – Public Health Emergency Isolation Order issued July 1, 2020 requires any individual who has tested positive for or who is likely to have COVID-19 to stay home and not report to work, until the individual has recovered from COVID-19.

7. I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this form is a voluntary act on my part. I also understand that my signing of this form is applicable only to mandatory COVID-19 testing during the week of 04/14/2021, and is not a consent or acknowledgement for any future COVID-19 testing required by the City of Carson.

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