ASSUMPTION OF THE RISK, WAIVER OF LIABILITY

RELATING TO COVID19 VOLUNTEER AND UNDERTAKING

(This serves as an Assumption of the Risk, Waiver of Liability Relating to COVID-19 and
Undertaking for Medical Clerks, Post-graduate Interns (PGI), Residency and Fellowship applicants
undergoing evaluation, and other non-medical Training rotators (e.g., OJTs, nursing students,
pharmacy students, med tech interns, rad tech interns, etc.), who are willing to volunteer to rotate
in Rizal Medical Center Units identified as high-risk for COVID-19 Transmission)

Rizal Medical Center generally prohibits resident-applicants and student/post graduate interns,
affiliates, and other training rotators, from entry to high-risk areas or attending to patients who are
likely to transmit SARS CoV2. It has put in place preventative measures to reduce the spread of
COVID-19; however, the hospital management and its units cannot guarantee that you will not
become infected with COVID-19 in the course of training and provision of care to patients.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily
assume the risk that I may be exposed to or infected by COVID-19 during my intended rotation,
and that such exposure or infection may result in personal injury, illness, permanent disability, and
death.

Having full knowledge and understanding of the risks involved, I am hereby willingly,
conscientiously and freely giving my consent to be assigned as rotator to high-risk patient areas.

Further, I agree with the following statements:

1. The risks of rotating in these posts were fully explained to me prior to signing this waiver
including the following but no limited to:
● The risks of exposure and subsequent COVID-19 disease (asymptomatic, mild, moderate,
severe or critical disease) and/or other highly-transmissible infections.
● The risk of physical and other injuries arising from patient care or other tasks.
2. That I shall continue to be bound by the rules, regulations and policies of the Rizal Medical
Center including, but not limited to:
● Standard practices of health care management
● Infection prevention and control
● Self-provision of PPEs
● Proper donning and doffing of PPEs
● Data privacy
3. That I am not allowed to take pictures of patients, make statements regarding patient care,
hospital affairs and hospital employees, or share the same in social media and other platforms
4. That I am not an authorized entity to be interviewed by media in any platform.
5. That my parents or legal guardian/s are fully aware and do concur with my intent to rotate in
high-risk areas.
6. That I will pull out from this rotation if in my own assessment, I am compromised or my work
environment becomes unsafe. In such cases, I will inform my designated supervisor.
7. That I will hold Rizal Medical Center, its director, officers, and employees, free and harmless
from all responsibility, claims, liabilities and/or obligations arising from or incurred in connection
with my own negligent act or omission during my rotation.
8. This agreement can be terminated anytime based on the individual discretion of the
department or the institution

_________________________________ _______________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
Postgraduate / Student Trainee Parent/Guardian

________________________________ ______________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
Department Training Officer Department Chair
TO-Form No. 030
Revision No. 0 29 April 2021