METADATA
last updated: 2025-12-15 RT updated metadata after BA fixed inconsistencies
file_name: Consent Adult and Minor CC3 - RT Ctrl.md
file_date: 2022-04-14
title: Consent Adult and Minor CC3 - RT Ctrl
category: guides
subcategory: test-site
tags: surveillance
source_file_type: gdoc
xfile_type: docx
gfile_url: https://docs.google.com/document/d/1Pf-n0xZRnbGOfqi7SqMR25_3LfaKdTq2fd5vvN3FOP0
xfile_github_download_url: https://raw.githubusercontent.com/FocusOnFoundationsNonprofit/floodlamp-archive/main/guides/test-site/Consent%20Adult%20and%20Minor%20CC3%20-%20RT%20Ctrl.docx
pdf_gdrive_url: https://drive.google.com/file/d/1PTBMz0IaQtJwJ7Ku-X67Ez7rMVPDNzCL
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/guides/test-site/Consent%20Adult%20and%20Minor%20CC3%20-%20RT%20Ctrl.pdf
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license: CC BY 4.0 - https://creativecommons.org/licenses/by/4.0/
tokens: 794
words: 467
notes: 
summary_short: The FloodLAMP “Voluntary Non-Diagnostic Surveillance Test Consent and Waiver” is an adult-and-minor consent form authorizing collection and non-diagnostic molecular surveillance testing for SARS-CoV-2. It explains that individual results are not provided, outlines referral expectations for diagnostic testing if a pool/individual indicates potential infection, and states key limitations (not a CLIA lab, not medical care). It also includes data disclosure terms to public health authorities, liability waivers, revocation instructions, and signature lines for the participant/guardian and listed minors.


CONTENT

***INTERNAL TITLE:*** FloodLAMP Voluntary Non-Diagnostic Surveillance Test Consent and Waiver

I am the "Participant", and parent or legal guardian of each minor child identified on this form, also Participants. Each Participant on this Consent and Waiver understands and agrees to the following:
1.  I grant FloodLAMP Biotechnologies permission to perform a non-diagnostic molecular surveillance test (the "Test") of the Participant's sample to indicate the potential presence of SARS-CoV-2, the virus that causes COVID-19.
2.  I understand that I will not be given individual results from the Test. In the event the Participant's individual or pooled sample indicates the presence of the SARS-CoV-2 virus, I will be referred to have the Participant take a diagnostic test.
3.  If referred to a diagnostic test, I agree to make a best effort at obtaining a diagnostic test for the Participant in a timely manner.
4.  I will not use the referral to a diagnostic test as a substitute for individual diagnostic testing.
5.  I agree not to rely on information received from FloodLAMP surveillance testing for decision making purposes.
6.  I agree not to misrepresent the purpose of this non-diagnostic surveillance Test.
7.  The Test is not being performed in a CLIA laboratory.
8.  The purpose of the Test is to improve public health and to determine appropriate mitigation measures for a population. The Test is not for individual medical or diagnostic purposes.
9.  I understand the Test does not rule out the possibility that the Participant may have been exposed to or is infected with SARS-CoV-2.
10. I understand that FloodLAMP Biotechnologies is not acting as the Participant's medical provider, and that the Test does not replace treatment by a medical provider. I agree that I will seek medical advice, care, and treatment from a medical provider for the Participant if I have questions or concerns.
11. The Participant's sample will be used for the sole, exclusive purpose of performing the Test. Results obtained will be used for the purpose of SARS-CoV-2 public health surveillance, as described herein.
12. I acknowledge and agree that FloodLAMP Biotechnologies may disclose Test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be required or permitted by law.
13. I expressly waive and release FloodLAMP Biotechnologies and its employees and agents from any and all rights, claims, lawsuits or damages of any nature whatsoever arising directly or indirectly from my participation in the Test or testing program.
14. If at any time, I choose to revoke consent as provided here, said revocation must be received by FloodLAMP Biotechnologies in writing or by email at support@floodlamp.bio.

Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Print Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This form is provided on behalf of the minor children identified as:

Print Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Print Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Print Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Print Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_