Provincial Antigen Screening Program Agreement
Before completing the Order form below, please ensure you have read ALL of the information on our website about participating in this program.
Once you complete the order form, the Kenora Chamber will notify you with your pickup date and time.
Please note that participating in this program requires you to report ALL test results.
Please ensure all information inputted is accurate. You cannot edit this form once it is submitted.
Number of Employees
Contact - The contact Name, Email and phone number entered should reflect who your organization has chosen to be the Screening Supervisor. This is the same person who will pickup the order.
Contact Name (First & Last)
Contact email address
Contact Phone Number
Terms and Conditions
• At present, COVID-19 rapid antigen testing is primarily conducted through the provincial public health care system.
• To assist in facilitating private sector screening, the Kenora & District Chamber of Commerce (“the Chamber”) has partnered with the federal and provincial governments to assist in the distribution of Rapid Antigen Tests to private businesses seeking to implement Point of Care (“POC”) screening at their workplaces.
• As the Business has resumed operations, or in order to continue operating, the Business has expressed interest in privately conducting asymptomatic testing and/or offering testing to employees who are not eligible for publicly-funded testing under the current.
Accordingly, the Chamber has agreed to provide the Business with Rapid Antigen Test kits in accordance with the following terms:
1. As part of the Ministry of Health and Health Canada, you are agreeing to participate in a “Supervised Self-Screening Program” for workplace employee screening. This program is under the sole responsibility and discretion of the Province of Ontario. The Province makes no guarantees about the availability or volumes of Screening Kits that may be available.
2. The Screening Kits provided by the Province to you are provided free of charge, on an “as-is” basis. Other than any warranty provided by the manufacturer, Ontario disclaims any and all representations, warranties and conditions, whether express, implied, written or oral, in relation to the Screening Kits, including fitness for use for any particular purpose.
3. The Province is bound by the Freedom of Information and Protection of Privacy Act (Ontario) and that any information provided to the Province in connection with the Program may be subject to disclosure in accordance with that Act.
4. You MUST:
Ensure that the Screening Kits are:
i. Used only for the purposes of the PASP (Provincial Antigen Screening Program).
ii. Not resold or distributed to any other person.
Report ALL data regarding results of the Screening Kits, failure to do so will result in future inability to participate in the program.
In providing COVID-19 point-of-care antigen testing to individuals using the Screening Kits at your site, ensure compliance with all applicable laws, provincial or federal directives, and provincial or federal guidance, including:
i. Ministry of Health COVID-19 Guidance: Considerations for Rapid Antigen Screening.
ii. Public Health Infection, Prevention and Control (IPAC) guidelines.
Supply, at your own cost, the appropriate human resources and all equipment and supplies (other than the Screening Kits themselves) required to perform the COVID-19 point-of-care antigen testing using the Screening Kits at your site.
Ensure that the person Supervising the COVID-19 rapid antigen testing using the Screening Kits at your site is a health professional OR is an individual that has participated in the training offered at the pickup site and has the appropriate knowledge, skills, judgement, and oversight to perform the test correctly. (It has been suggested that the Health and Safety Designate be appointed as the Screening Supervisor Designate.)
5. This agreement comes into effect upon execution and shall expire on March 31, 2022, unless terminated earlier in accordance with this section. Ontario may terminate this Agreement immediately upon written notice to you if you fail to comply with any term of this Agreement. For clarity, if the agreement is terminated, you shall no longer be participating in the PASP and shall not receive any further access to screening Kits from Ontario.
6. This Agreement is made under and shall be construed according to the laws of the province of Ontario and the laws of Canada applicable herein.
Waiver of Liability
In consideration of being permitted to participate in any way in the Rapid Antigen Screening Kit Program, I do hereby release, waive, discharge, and covenant not to hold the Kenora & District Chamber of Commerce liable from any and all claims resulting in personal injury, accidents, or illness arising from, but not limited to, participating the in the Rapid Antigen Screening Kit program.
I also agree to indemnify and hold the Kenora & District Chamber of Commerce, their officers, employees, volunteers and agents harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including fees brought as a result of my involvement in the Rapid Antigen Screening Kit program.
I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms. I acknowledge that I am signing the agreement freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability.
Terms and Conditions Agreement
I have read the terms and conditions (above) and I agree to the terms and conditions.
Have questions about the order form or the program? Please email
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