COVID-19 Acknowledgment and Consent

All fields marked with an asterisk (*) are required.

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Date

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Name*

First & Last Name

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CID*

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Email Address*

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Understanding for Participation*

I understand that in order to participate in and meet course/program objectives for the Angelo State University (ASU) Graduate Nursing Department clinical practicums and program courses, I will be required to travel to and from and be physically present in the clinical host ("Host") workplace(s) or on the ASU campus.

I acknowledge and consent to the inherent risk of exposure, contracting, and transmission of COVID-19.

I agree to follow all recommendations and guidelines related to prevention, treatment, and control of COVID-19 set by Host and Host personnel; ASU; and federal, state, and local authorities (including but not limited to those provided by the US Centers for Disease Control and Prevention (CDC).

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COVID-19 Screening & Symptoms*

I will self-screen for COVID-19 symptoms before reporting to practicum at Host location or to ASU and will fully disclose and report to The University and Host any signs and symptoms of COVID-19. These symptoms may include fever, shortness of breath or difficulty breathing, cough, chills, sore throat, body aches, muscle pain, fatigue, nausea, diarrhea, vomiting, lack of taste or smell, runny nose, or sinus congestion.

If I have been in contact with a COVID-19 infected person, I acknowledge that I may be required to quarantine for my safety and the safety of others.

I also acknowledge that the Host may require me to be periodically screened or tested

If I test positive for COVID-19, I understand that I may be required to isolate for my safety and the safety of others.

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Understanding of Inherent Risk*

I understand there is an inherent risk of contracting COVID-19 by participating in the clinical practicums and related program course activities.

I acknowledge that I have access to CDC provided educational materials pertaining to COVID-19 available at https://www.cdc.gov/coronavirus, including the background of the virus, how it spreads, and proper personal hygiene.

I acknowledge that if I do not follow these safeguards, I may not be allowed into the University or Host facilities.

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Acknowledgement*

By checking, I acknowledge that I have read the above and agree that the statements are accurate.

Link (required)