I hereby consent to undergo testing administered by SHIELD T3, LLC for the purpose of testing for the 2019 Novel Coronavirus, also known as Covid-19, throughout the Spring 2021 semester. I understand I can revoke this consent at any time. I hereby authorize SHIELD T3, LLC to use my health information obtained as a result of or in connection with this Covid-19 testing performed by SHIELD T3, LLC and further authorize the disclosure of said health information to the University of Maine System, with a primary address of 5703 Alumni Hall, Orono, ME 04469. I hereby acknowledge and agree that this Covid-19 testing performed by SHIELD T3, LLC is for the purpose of creating health information (e.g., Covid-19 test results) to be provided to the University of Maine System and that this consent form is required to be signed before I receive Covid-19 testing.

I understand that I will provide a saliva sample which will be tested by “saliva-to-RT-qPCR molecular testing for the qualitative detection of SARS-CoV-2”. This is a test intended to detect the presence of SARS-CoV-2 (the virus that causes COVID-19) in saliva. I understand that potential risks of this test include the possibility of incorrect test results due to false positives or false negatives.

I understand that SHIELD T3, LLC and the University of Maine System will maintain information disclosed under this consent form consistent with applicable laws and regulations. Information disclosed under this consent form may also be disclosed as otherwise required by law, for instance to the Centers for Disease Control and Prevention (CDC) for public health purposes. I understand any disclosure of information carries with it the potential for unauthorized redisclosure, which could result in the information no longer being protected. If I have questions about the use or disclosure of my health information, I may contact SHIELD T3, LLC at 506 South Wright Street MC 349, Urbana, IL 61801, or the University of Maine System at 5703 Alumni Hall, Orono, ME 04469.