RapidScreening

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Update May 2023

Type of Test*

I am completing my "once every 7 days" RAT I am completing my "enhanced/outbreak at location" RAT (before arriving at shift and once a day for 5 days) I am completing my "asymptomatic, close contact with member of household" RAT (complete once daily for 5 days) I am completing my "asymptomatic, one time close contact" RAT (complete once daily for 5 days) I am completing a count of remaining tests at the location

What actions are you taking?*

Performing a test AT A CLW LOCATION Performing a test AT HOME Counting tests remaining

There is no need to complete this form for Control Screen tests.

Location*

Location you are assigned to*

Date*

Time*

Testing

Name of person being tested*

First Name

Last Name

Test results*

Invalid Positive Negative

Also choose "Invalid" if a test is incomplete for any reason (like a person supported withdrawing consent). Make sure to make a note below.

Confirm- Invalid*

Confirmed

Since the test was invalid, please see instructions below:*

"Invalid" was the result on the test (1st attempt)- test again "Invalid" was the result on the 2nd attempt- Leave work ASAP, isolate, contact manager ASAP This is deemed "invalid" for another reason (like person supported withdrawing consent after materials were opened)

Select the most appropriate circumstance & corresponding instruction

Confirm- Positive*

Confirmed

Since the test was POSITIVE, there is action to take. *

I WILL- Leave the worksite ASAP, Isolate, Contact Manager ASAP

Remember that a "positive" test on the Rapid Screening is only a "preliminary positive." Take it seriously but do not panic. If you're having any difficulty call your Manager to talk.

Notes (REQUIRED if the test is "Invalid / Inconclusive"

A picture of the test result must be uploaded with this form

No File Chosen

File uploads may not work on some mobile devices.

Not required ONLY if test is performed at the CLW Testing Centre

How many INDIVIDUAL tests remain in the location (DO NOT COUNT # OF BOXES- PLEASE COUNT INDIVIDUAL TESTS). SEE BELOW.*

Eg. if you have 2 unopened boxes of 25 and an open box with 7 tests remaining, indicate "57"

Who counted?*

Email Confirmation

Please enter your email address if you would like a confirmation email