I have viewed the Emerge Diagnostics EFA-STM Program information video and received the list of Frequently Asked Questions. I have had an opportunity to have any questions regarding this EFA-STM Program answered to my satisfaction. I understand the EFA test is non-invasive, which means it does not involve tools that break the skin or physically enter the body, and the data, which is stored on a secure server by Emerge Diagnostics, is not evaluated or provided to anyone when the baseline test is conducted. The baseline test data is securely stored and unread.

CONSENT TO EFA

I voluntarily consent and agree to undergo an EFA baseline examination before my first day of employment with the Company that will record my physical status in relation to tasks and related work associated with my essential job duties, but the test will not be used in any way to determine whether I qualify for the role. I understand the EFA baseline evaluation will require me to perform range of motion actions while taped sensors record my muscle activity and function. I further consent and agree to undergo a post-incident EFA examination if I report a potential work-related incident during my employment with the Company. As part of the baseline and post-incident testing, I agree to show a photo ID to verify my name and will be asked to provide my date of birth, social security number, height, and weight. This information may also be provided to Emerge Diagnostics by the Company as my employer in the event of a second post incident test. I understand my date of birth and social security number are solely used to confirm my identity on the baseline and any future testing data that may need to be compared. Emerge agrees to only retain, use, and disclose this personal information for this limited business purpose. My personal information is stored on a secure server and never sold.

STATEMENT OF ABILITY TO PARTICIPATE

I agree I will be able to safely participate in the baseline testing without injury to myself and will participate to the best of my ability.

CONSENT TO RELEASE INFORMATION AND RECORDS

I consent and authorize any and all information, records, or other data obtained in connection with or related to the EFA-STM Program to be stored and evaluated by Emerge Diagnostics if I sustain and/or report a potential work-related incident during my employment with the Company that requires a second EFA evaluation. I consent and authorize Emerge Diagnostics to release a report to the Company as my employer about whether there was any change in my status, but such report will not include any underlying data. I understand that I, the Company as my employer and/or its third-party administrator may subpoena, and thereby receive a copy of, the underlying data to use in evaluating any claim I may make for Workers’ Compensation.

I acknowledge by signing below that I have read, understand, and agree to be bound by all the above statements and have not been coerced into doing so.