COVID19 Test Kit Consent Form

(Completed for all employees requesting COVID-19 Rapid Test Kits)
 
By completing and signing this form, I am volunatarily consenting to self-administer the COVID-19 Rapid Test provided by Prosper Home Care.
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Gender *
Hispanic or Latino *
**Race questions required if a positive result is returned when reporting to the Department of Health.
 
Any symptoms present (Check all that apply) *
Rapid Test Results *
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