Pick Up Form
PLEASE READ BEFORE ORDERING.

The Chamber will notify you when your kits are ready for pick-up. Your Screening Supervisor Designate will be required to watch a 6-minute instructional video on properly conducting the self screening, which can then be shared with all your employees. DO NOT SEND a relative, friend or driver for your first pickup.

If you are ONLY interested in ordering masks (not the self screening kits), please check off the box that reads " I am only interested in ordering surgical-grade face masks".

Businesses ordering self screening kits will automatically receive masks.

If you are ordering refills, you MUST have reported your results as per the Provincial Antigen Screening Program Agreement. We will not refills orders unless you have reported the results for 75% of the screening kits that you picked up.

The workplace self screening program offered by the Greater Kitchener Waterloo and Cambridge Chambers of Commerce is only available to businesses in the Region of Waterloo .

Please DO NOT visit the pick-up locations until you have heard from us.
Business Name *
Contact Name *
Email Address *
City (Business Location) *
Telephone Number *
Number of Employees *
Pick Up Location *
Picking up your order *
Program Agreement/Commitment
TERMS AND CONDITIONS FOR PROVINCIAL ANTIGEN SCREENING PROGRAM

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:
a. 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.
b. Report ALL data regarding results of the Screening Kits at www.ChamberCheck.ca, failure to do so will result in future
inability to participate in the program.
c. 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.
d. 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.
e. Ensure that the person Supervising the COVID-19 rapid antigen testing using the Screening Kits at your site, has
participated in the training offered at the pickup site. (suggestion is that the Health and Safety designate be appointed as the
Supervising Screener).

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 therein.
Terms and Conditions *
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