Precision Pulmonary Diagnostics

Step 1 of 3

Identifying Information

Last Name

First Name

Company
Sysco

Last four digits of Social Security Number
Driver Code Not Found This driver has already taken the survey.

Driver Phone

Driver Cell Phone

Driver Email

Classification:

License Classification:

Operating Group:

Operating Company

Applicant Experience

CONSENT TO DISCLOSURE OF PERSONAL INFORMATION

The information I have provided on the Somni-Sage survey is correct.  The detailed answers to the questions on the survey itself will be disclosed only to PPD as a screening tool for Sleep Apnea.  This information will be used to determine my health risk for a medical diagnosis known as Obstructive Sleep Apnea.  Should I test positive my diagnosis will not be shared beyond Sysco or PPD's authorized agents.   This information may be used for statistical purposes and is proprietary to Sysco and PPD.
I authorize a copy of my sleep study results to be released ( including electronically) to authorized Sysco representatives. Should the study validate a diagnosis of sleep apnea, I authorize copies of the compliance data from my sleep apnea treatment equipment (CPAP) to be released ( including electronically) to authorized Sysco representatives.
I understand that I or my authorized representative will receive a copy of this authorization upon request.  This authorization is good for as long as I am a Sysco employee. Statistically there is no expiration on the use of this data.  
I understand that I may inspect and receive a copy of the protected health information to be released and disclosed pursuant to this Authorization Form.  I understand that I may also request a copy of this Authorization Form. By signing below, I acknowledge that my signature is voluntary and I understand that I am not required to sign this form in exchange for receiving health care treatment.
 By not agreeing to the policy below you have elected not to participate in the Sleep Apnea Survey, CLICK HERE to return to the Sysco Portal or check the box below to proceed with the survey.
You have the right to revoke this authorization, except to the extent that use and disclosure of your protected health information has been made in reliance on this authorization.  To revoke your authorization please notify PPD at 713-520-5864. Once your authorization has been received, it may take up to five (5)  business days for us to process your revocation.

I agree to the HIPAA Policy

GINA Policy

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide or collect any genetic information when responding to this request for medical information. "Genetic information" as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

I agree to the GINA Policy

SOMNI-SAGE® Health Screening Survey

Step 1 of 3

Identifying Information