Dear Team:

Our goal is to provide a safe environment for our team, patients, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand with the risk of working on patients and with fellow team members during this COVID - 19 pandemic within the confines of our office(s).

The COVID - 19 virus is a serious and highly contagious disease. The World Health Organization has classified this as a pandemic. You could contract COVID - 19 from a variety of sources and PSP wants to ensure you are aware of risks of contacting COVID -19 associated with treating emergency patients or being in close proximity of fellow team members.

The COVID -19 virus has a long incubation period.  Determining who is infected by COVID - 19 is challenging and complicated yet we are taking every measure available to limit the potential of infection by screening all employees as well as patients who enter the facility.  You must understand, even with measures in place to limit exposure and transmission, that there is still a risk of contracting or transmitting COVID - 19.

By signing this form you confirm and are consenting that you have read the notice above and understand and accept that there is a risk of contracting the COVID -19 virus while working on patients within the confines of PSP. You also acknowledge that you could contract the COVID -19 virus from outside the office that are unrelated to working here and bear the responsibility of self assessing as to whether you are potentially infected. You have also been informed that work is 100% voluntary at this time with no risk of sacrificing your long term position if you elect not to work now for any reason.

If you are asked and consent to work, you must answer all screening questions that indicate that you are free of the COVID - 19 virus.