Self Screening Pickup Form

The Chamber will notify you when your kits are ready for pick-up. Your Screening Supervisor Designate will be required to watch a 5-minute instructional video on properly conducting the self screening, which can then be shared with all your employees.

If you are ordering refills, you MUST have reported your results as per the Provincial Antigen Screening Program Agreement.

Please DO NOT visit the pick-up locations until you have heard from us.

* Required

Business Name(Required)

Contact Name(Required)

First Last

Email(Required)

City (Business Location(Required)

Phone(Required)

Number of Employees(Required)

Pick Up Location(Required)

Picking Up Your Order(Required)

I have read the terms and conditions (below) and I agree to the terms and conditions(Required)

Agree

Program Agreement/Commitment

TERMS AND CONDITIONS FOR PROVINCIAL ANTIGEN SCREENING PROGRAM

As an Eligible Business receiving a Test Kit from the Tillsonburg District Chamber of Commerce, you agree to the following terms:

a. Eligible Businesses that receive the Test Kits must ensure that the Test Kits are:

i. Used only for the purposes of the Initiative.

ii. Not resold or distributed to any other person.

b. Eligible Businesses that receive the Test Kits must report the following data regarding use of the Test Kits to the Chamber, at least once every seven (7) calendar days:

iii. Number of rapid antigen tests used;

iv. Number of individuals who tested positive with a rapid antigen test;

v. Number of individuals who tested negative with a rapid antigen test; and

c. Eligible Businesses shall ensure that there is no fee charged to persons being screened using the Test Kits. Such screening must be provided free of charge to the person being tested.

d. In providing COVID-19 point-of-care antigen testing to individuals using the Test Kits at their sites, Eligible Businesses that receive the Test Kits must 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.

e. Eligible Businesses that receive the Test Kits must supply, at the business’ own cost, the appropriate human resources and all equipment and supplies (other than the Test Kits themselves) required to perform the COVID-19 point-of-care antigen testing using the Test Kits at their site.

f. Eligible Businesses that receive the Test Kits must ensure that the person performing COVID-19 point-of-care antigen testing using the Test Kits at their site must be a health professional or trained individual that has the appropriate knowledge, skills, judgment, and oversight to perform the test correctly.

Additionally, the Eligible Business agrees to hold harmless the Tillsonburg District Chamber of Commerce from and against all losses, costs, liabilities, claims, damages and expenses of every kind and character, as incurred, resulting from or relating to or arising out of participation in the Provincial Antigen Screening Program.