HYDROFORM USA

RESPONSIBLE EMPLOYER COVID-19 TESTING

COMPLETE EMPLOYEE WAIVER BELOW

 

CONSENT AND RELEASE RELATED TO MANDATORY COVID-19 TESTING

Purpose: To consent to taking a COVID-19 viral test during the week of 01/19/2021 and provide results of said test to Hydroform USA.

I am an employee of the Hydroform USA 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, Hydroform USA is offering a self-administered, easier-to-use nasal swab test provided by US Health Fairs.org (www.ushealthfairs.org) at the facilities of Hydroform USA located at 12950 San Fernando Rd., Sylmar, CA. 91342.

2. I agree to submit the test results or authorize the release of the test results to Hydroform USA.

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 Hydroform USA from disclosing my medical/health information, including the test results, to unauthorized individuals. I understand that Hydroform USA 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 Hydroform USA. 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 Hydroform USA, 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 01/19/2021, and is not a consent or acknowledgement for any future COVID-19 testing required by Hydroform USA.

Preventive Health Education is Our Mission

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info@ushealthfairs.org

3751 Motor Ave., Suite 173, Los Angeles, CA 90034