COVID-19 Screening Program Consent and Authorization
Global Health Solutions (“GHS”) has been procured by York University to provide COVID-19 Rapid Antigen Testing clinics as part of York University’s COVID-19 Screening Program. As part of this program, GHS has retained a physician to oversee its Rapid Antigen Testing program and for requisition of COVID-19 PCR tests in the event of a positive Rapid Antigen Test.
You have been requested to participate in York University’s onsite COVID-19 Screening Program. For more information, please contact via email at YORK-YUTestingClinic@yuoffice.yorku.ca.
Your personal information (including personal health information) will be collected pursuant to applicable privacy law.
If you have any questions about the collection, use and disclosure of personal information by York University, please contact: Information, Privacy & Copyright Office – 4700 Keele St, 416-736-2100x40706, email@example.com.
Consent and Authorization
- I hereby freely consent to permit GHS (and its Third-Party Service Provider or Third-Party Physician, where applicable) to collect, use, retain, and disclose my personal information for administering services related to the COVID-19 Screening Program. I agree that my personal health information may be used for the following purposes:
- I understand that if my test indicates I am positive for COVID-19, I will be contacted by a York University Case Manager overseeing the COVID-19 Screening Program. Additionally, I understand that this person or GHS may also notify York University of the positive test result for the purpose of ensuring a safe campus.
- I understand and agree that if my test indicates I am positive for COVID-19, GHS or its Third-Party Service Provider/Third-Party Physician is obligated to report this to the appropriate provincial public health authority. Public Health will be provided with my name, address and phone number to enable contact tracing and the provision of COVID-19 support services as needed. I further understand that Public Health may contact me as part of their obligations under Provincial Health surveillance regulations.
- Notwithstanding, my personal health information will not be disclosed except as required to support the operation of York University or as required by applicable law or directive of any relevant public authority related to the COVID-19 pandemic.
- I have read and understood the information contained in this consent including how my information will be collected, used and disclosed by GHS (including any Third-Party Service Provider or Third-Party Physician) and am aware of the risks or benefits of consenting, or refusing to consent.