City of Rosemead COVID-19 Test Home Collection Kit for Rosemead Residents

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Email *

What is your Kit reservation number that was sent to you by email? *

What is your last name? *

What is your first name? *

Have you previously requested a Rosemead COVID-19 Test Home Collection Kit? (Please do not submit a duplicate request as it will be rejected and will slow down processing of other resident requests) *

If yes, what was the prior received Kit number(s)? If you did not receive a Kit before, please enter "n/a". *

Due to limited supply, request may be denied if a Kit has been received before to allow as many Rosemead residents have the opportunity to participate in the program.

The COVID-19 Test Home Collection Kit is made available by the City of Rosemead for Rosemead residents that are showing potential SARS-CoV-2 symptoms or have had potential exposure. You will be asked to provide proof of Rosemead residency by submitting a copy of your driver's license, current utility bill, current rent receipt, or other acceptable documentation. Are you able to submit the proof of Rosemead residency? *

What is your home address? House number and street name (example: 8838 Valley Blvd.) *

Name of the City for the above home address? (example: Rosemead) If you do not currently reside in Rosemead, please do not submit this request form. *

Test collection kit eligibility is determined in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. The test kit taker must be 18+ years old. COVID-19 is caused by the SARS-CoV-2 virus. Infection with the virus can range from being asymptomatic to life-threatening respiratory illness. Infection has been detected globally and in all 50 states. Symptoms associated with COVID-19 include cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or new loss of taste or smell. COVID-19 can present with severe illness in individuals of any age and without any previous health problems, but the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Having underlying medical conditions may also increase one’s risk for severe illness from COVID-19. Conditions and other risk factors that may be associated with severe illness and death are listed below. If you have any symptoms concerning for COVID-19 and any of the following conditions or risk factors, which may put you at increased risk of severe illness from COVID-19, you should consult with your healthcare provider before using this test: Chronic kidney disease; COPD (chronic obstructive pulmonary disease); Immunocompromised state (weakened immune system) from solid organ transplant or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines; Obesity (body mass index [BMI] of 30 or higher); Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies; Sickle cell disease; Type 2 diabetes mellitus; Asthma (moderate-to-severe); Cerebrovascular disease (affects blood vessels and blood supply to the brain); Cystic fibrosis Neurologic conditions, such as dementia Liver disease Pregnancy; Pulmonary fibrosis (having damaged or scarred lung tissues); Smoking; Thalassemia (a type of blood disorder); Type 1 diabetes mellitus. Regardless of your risk status, it is recommended that you immediately seek emergency care if you experience trouble breathing, persistent pain or pressure in the chest, an inability to wake up or stay awake, or bluish lips or face. Regardless of your risk status, if you are experiencing any of the following emergency warning signs for COVID-19, it is recommended that you immediately seek emergency care: Trouble breathing; Persistent pain or pressure in the chest; New confusion; Inability to wake up or stay awake; Bluish lips or face. *

I have read and acknowledge the above.

Required

Are you 18-years or older? Test collection Kit eligibility is determined in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. The test kit taker must be 18-years or older. *

How would you rate your symptoms right now? *

No symptoms - I am not having any symptoms, or I am having symptoms that are not listed in the other two choices.

Mild symptoms - I have a fever between 100.4°F and 102°F, am feeling feverish, or feel warm to the touch. I am having flu-like symptoms (chills, runny or stuffy nose, whole body aches, a headache, and/or feeling tired). I have new loss of taste or smell. I have a new or worsening cough. I am having shortness of breath that is not limiting my ability to speak

Severe symptoms - I have a high fever of greater than 102°F, OR I have a high fever that has lasted longer than 48 hours. I can’t speak in full sentences or do simple activities without feeling short of breath. I am having severe coughing spells, or I am coughing up blood. My lips or face are blue. I have severe and constant pain or pressure in my chest. I feel very tired or lethargic. I feel dizzy, lightheaded, or too weak to stand. I am having slurred speech or seizures. I do not feel like I can stay at home because I feel seriously ill.

Please describe your exposure to Coronavirus *

No exposure - I have not been exposed to COVID-19.

Potential exposure - I live or work in a place where people reside, meet or gather in close proximity (office buildings, schools, healthcare facilities, etc.).

Suspected exposure - I have been in close proximity (within 6 ft) to someone who is sick but not diagnosed with COVID-19.

Known exposure - I have been in close proximity (within 6 ft) to someone who has been diagnosed or presumed to have COVID-19.

Please check below acknowledging COVID-19 Home Testing Kit terms and conditions. *

I acknowledge that I have answered these questions truthfully to the best of my knowledge and that the COVID-19 Test Home Collection Kit will only be used by me for my personal use. I further understand that I may be liable for reimbursement for cost of the kit ($109.00) if I do not use it for personal use.

Required

RELEASE OF LIABILITY – COVID-19 TEST HOME COLLECTION KIT PROGRAM. I, the undersigned, wish to participate in the City of Rosemead’s COVID-19 Test Home Collection Kit Program (“Program”). The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. The City has purchased COVID-19 Sample Collection and Test Kits from EverlyWell, Inc. (“Test Kits”) and has made the Test Kits available through the Program upon application for the voluntary use by City residents, but the City makes no representations or warranties (express, implied, statutory or otherwise) with respect to such Test Kits, its accuracy, or its safety. I fully understand that participation in the Program exposes the participant to the risk of personal injury and that it is each participant’s responsibility to carefully evaluate their own health conditions, the Test Kits, and the risks of using the Test Kits. I understand that there are risks inherent in participating in such Program and using such Test Kit. I agree to assume all of the risks and accept sole responsibility for participating in the Program and using the Test Kits. In consideration of being permitted to participate in this Program, I release, discharge, and agree (for myself, my heirs, administrators, executors and assigns) not to sue, the City for any personal injury arising out of, or in connection with, any participation in the Program or the use of the Test Kits. I further agree to indemnify and hold harmless the City from any and all claims, demands, actions, or suits arising out of, or in connection, with, my participation in the Program or my use of the Test Kits. I HAVE CAREFULLY READ THIS RELEASE OF LIABILITY AND UNDERSTAND THAT I WILL HOLD THE CITY HARMLESS AND AGREE NOT TO SUE AS A CONDITION OF PARTICIPATING IN THIS PROGRAM AND THE USE OF THE TEST KITS. I FULLY UNDERSTAND THE CONTENTS IN THIS RELEASE AND THAT IT IS A FULL RELEASE OF ALL LIABILITY. I SIGN THIS RELEASE OF MY OWN FREE WILL ON BEHALF OF MYSELF, MY HEIRS, ADMINISTRATORS, EXECUTORS AND ASSIGNS, AND MY SUCCESSORS. *

I Agree. By clicking "I agree" you are providing your consent and agreement to this Waiver form.

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A copy of your responses will be emailed to the address you provided.

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