Administrative Procedure 449 Appendix B

COVID-19 Rapid Test Attestation

I, ________________________________________ (first and last name), an employee of Fort McMurray School Division, confirm through submission of this form that on ____/____/________ (dd/mm/yyyy) at ______________ (hour) a.m./p.m., I performed the Health Canada approved COVID-19 Rapid test that I have received pre-approval by the Division to use pursuant to Administrative Procedure 449. I have strictly followed the instructions provided with the testing kit and confirm that the result of this test was:


[  ] Negative

[  ] Positive


I understand that knowingly submitting a false result of the test or tampering with the test to create a false result is an extremely serious breach of the terms and conditions of my employment. I understand that such conduct would result in severe disciplinary action up to and including consideration of immediate dismissal for just cause.

Employee Signature   Date (dd/mm/yyyy)


December, 21, 2021

Cross Reference:

AP 449 Hazard Mitigation Employees, Volunteers and Others

AP 449 Appendix A Hazard Mitigation Employees, Volunteers and Others