NATIONAL KIDNEY AND TRANSPLANT INSTITUTE

Office of Education, Training and Research Services

East Avenue, Diliman, Quezon City, 1101 Philippines
Tel. Nos.: 8981-0300/8981-0400 | Website: www.nkti.gov.ph | Email: medical.education@nkti.gov.ph

JUNIOR INTERSHIP/ CLINICAL CLERK ROTATORS

ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO COVID-19

The World Health Organization (WHO) has declared the novel Coronavirus (COVID-19) a
worldwide pandemic. Due to its capacity to transmit from person-to-person through
respiratory droplets, the government has set recommendations, guidelines, and some
prohibitions which the National Kidney and Transplant Institute (NKTI) adheres to comply.
NKTI has put in place preventative measures to reduce the spread of COVID-19; however, it
is not a guarantee that a person may not become infected with COVID-19. Further, attending
the internship/clerkship clinical ward work could increase your risk of contracting COVID-19.

In consideration of my participation in the foregoing, the undersigned acknowledge and

agree to the following requirements set by the NKTI:

 I am aware of the existence of the risk on my physical presence during my rotation period
at NKTI which includes participation in various activities at the NKTI that may cause
illness and other related repercussions due to COVID-19;

 I will submit my negative (-) COVID RT-PCR result and normal chest X-ray result done
within five (5) days prior to the commencement of my rotation at the NKTI to the
Division/Department I will be rotating and to Education, Training and Research Services
(ETRS) Office;

 I will not be assigned to the COVID Wards, Intensive Medical Care Unit (IMCU) and
Emergency Room (ER) during my rotation in NKTI; and

 I will not report to my mother agency/hospital during my rotation period to limit the
possibility of cross contamination with COVID-19 from one hospital to another.

Following the pronouncements above, I hereby declare the following:

 I am fully and personally responsible for my own safety and actions while and during my
rotation period at NKTI and I recognize that I may be at risk of contracting COVID-19;

 With full knowledge of the risks involved, I hereby release, waive, discharge the NKTI, its
board, officers, affiliates, employees, representatives and assigns from any and all
liabilities, claims, demands, actions, and causes of action whatsoever, directly or
indirectly arising out of or related to any loss, damage, injury, or death, that may be
sustained by me related to COVID-19 while participating in any activity while in, on, or
around the premises or while using the facilities that may lead to unintentional exposure
or harm due to COVID-19; and

 I agree to indemnify, defend, and hold harmless the NKTI from and against any and all
costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or

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Version 1 dated April 14, 2022
 NATIONAL KIDNEY AND TRANSPLANT INSTITUTE
Office of Education, Training and Research Services
East Avenue, Diliman, Quezon City, 1101 Philippines
Tel. Nos.: 8981-0300/8981-0400 | Website: www.nkti.gov.ph | Email: medical.education@nkti.gov.ph

indirectly from or related to any and all claims made by or against any of the released
party due to injury, loss, or death from or related to COVID-19.

By signing below, I acknowledge that I have read the foregoing Assumption of Risk and
Waiver of Liability Relating to COVID-19 and fully understand its contents; that I am fully
competent to give my consent; that I have been sufficiently informed of the risks involved
and give my voluntary consent with my own free act and deed in signing this Assumption of
Risk and Waiver of Liability Relating to COVID-19, with full intention to be bound by the
same, without any inducement or representation.

Name and Signature of Junior Intern/ Clinical Clerk

Last Name, First Name, Middle Initial Signature Date Signed (mm/dd/yyyy)

ATTESTED BY:

Name and Signature of Department/Division/Section Head of Junior Intern/ Clinical Clerk

Last Name, First Name, Middle Initial Signature Date Signed (mm/dd/yyyy)

Name and Signature of Head of Agency

Last Name, First Name, Middle Initial Signature Date Signed (mm/dd/yyyy)

Note: Please submit the signed waiver at least five (5) days before the start of rotation at NKTI.

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Version 1 dated April 14, 2022