Test covid19 form

Test covid19 form



INFORMATIVE Coronavirus – SARS- Cov-2 rapid test on type E swab card Pathogen characteristics

SARS-CoV-2 (Coronavirus 2 of SARS) is the causative etiologic agent of COVID-19 (Corona Virus Disease¬2019).

Test Characteristics
1.The “PanbioTM COVID-19 Ag Rapid Test Device ” is an in vitro rapid diagnostic test for the qualitative detection of SARS CoV-2 antigen (Ag) in human nasopharyngeal swab specimens from individuals who meet COVID-19 clinical and/or epidemiological criteria. The PanbioTM COVID-19 Ag Rapid Test Device is for professional use only and is intended to be used as an aid in the diagnosis of SARSCoV2 infection.
2.The test provides preliminary results. Negative results do not preclude SARS-CoV-2 infection and cannot be used as the sole basis for treatment or other management decisions. Negative results should be combined with clinical observations, patient history, and epidemiologic information.
3.Test for rapid, card-based investigations involving nasopharyngeal swab collection, with subsequent rapid processing for deposition and reading by immunochromatographic technique on cards for qualitative detection of SARS CoV-2-specific antigens,
4. (the “Test”) DOES NOT REPLACE the search for viral RNA by molecular technique (from nasopharyngeal swab) which, for the moment, is the only definitively diagnostic, as per Ministerial Circular No. 0016106 of 09/05/2020 and subsequent amendments, which specifies that the test is useful in the epidemiological assessment of virus circulation.

How it is performed
The test is performed with nasopharyngeal swab, carried out as per current regulations and allows the qualitative search for specific antigens for SARS CoV-2,
Possible results of the test
1. NEGATIVE or NON-REACTIVE result for SARS CoV-2 specific antigens,
2. POSITIVE or REACTIVE result for SARS CoV-2 specific antigens,
3. Doubtful result possible interference of SARS CoV-2 specific antigens.
Doubtful or positive results will still need to be confirmed by nasopharyngeal swab, for molecular RT-PCR diagnostic testing.
In case of a POSITIVE result, the patient will have to undergo independently the measure of fiduciary home isolation and undergo as soon as possible the nasopharyngeal swab for viral RNA.

Expression and acquisition of informed consent:



I, the undersigned


declare that I have received and understood the information relating to the performance of the requested diagnostic examination.
I am aware that I may revoke this consent at any time before the examination is performed.



I DECLARE

that I have received full explanations from the person responsible for carrying out the test, that the test has important values for research and epidemiological evaluation of the viral circulation and that I have read and understood the information and:

CONSENTDO NOT CONSENT




the execution of the Coronavirus - SARS- Cov-2 RNA viral examination, consenting to the transmission of the results to the authorities for epidemiological purposes (where applicable), in full compliance with the applicable privacy legislation
























CONSENT TO THE PROCESSING OF PERSONAL DATA FOR THE E-MAIL TRANSMISSION OF THE RINO PHARYNGEAL TEST RESULTS - EMERGENCY SITUATION FROM CORONA VIRUS
pursuant to Article 6 letters A and 7 of E.R. 2016/679



MrMrs










For him/herselfas a legal representative

support administratorparentguardian









DETAILS OF THE LEGAL REPRESENTATIVE'S DOCUMENT


PassportIdentity CardOther



I DECLARE
o have received the information for the processing of personal data relating to the service of forwarding via e-mail the results of the rino pharyngeal tests, to authorize the processing of my personal and particular data (as per art. 9 of EU Regulation 2016/679) for the purpose of sending my medical and health data as a result of the services requested, as part of the activities related to the COVID-19 emergency, to exempt the Azienda Sanitaria Provinciale di Palermo, from any liability in the event of loss, delay, non-receipt, access to the document by a third party other than the person concerned or any violation of data protection regulations and/or other circumstances, not attributable to the same, caused by sending the requested report by e-mail.
This consent is signed by the interested party at the time of the request to send the report by e-mail and will be considered valid for the use of the service in relation to each individual examination to which the interested party will submit, unless otherwise requested by the interested party who is not affected by the right to suspend / revoke at any time or to restrict its operation to certain checks or to request the deletion, even partial, of certain personal data.


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