Port Chester Public Schools COVID-19 Testing Consent Form
The Port Chester School District is committed to keeping our schools open for in-person instruction for as long as it is safe for students and employees. The New York State Department of Health revised its guidelines for schools related to COVID-19 micro-clusters. Port Chester is currently designated as an "orange zone" by NYS, COVID-19 testing would be mandatory in order for schools in the community to reopen. School districts will be required to conduct COVID-19 testing on 20% of the on-site school population over a four-week period. Testing needs to be based on a random sampling of students and employees. To maximize in-person instruction for students, the District is seeking your advance consent to participate in free COVID-19 testing provided at school either by trained school nurses or, if you authorize your child to be treated at one of our Open Door School Based Health Centers, by trained health care providers at a School Based Health Center. The scheduling of on-site COVID-19 screening tests will occur at a future date.

As the district prepares to fulfill the potential testing requirement, we will be using a minimally-invasive nasal swab test (a nasal swab of the front and sides of each nostril). Any testing done would adhere to all federal and state privacy laws, and all test results shall remain confidential, except as required by law. Your child may be tested throughout the school year in accordance with state and county health department guidelines. If you consent, then your child may be selected for testing on one or more occasions depending on our designation and health department requirements. The test is free and results are available in about 15 minutes. We encourage your participation so that we can keep our schools open and make them safer. To see a brief video about the COVID-19 screening test to be used, visit https://www.globalpointofcare.abbott/en/product-details/navica-binaxnow-covid-19-us.html#.

Students testing positive would need to go home immediately, and their parents/guardian would be notified if you have not already accompanied your child to the testing. If your child tests positive, upon leaving the test site, please contact your child's healthcare provider to review the test results and discuss what you should do next. Per health department guidelines, you will be asked to keep your child at home for a 14-day period of quarantine.

The law allows some information about your child to be shared with the New York State Department of Health and Westchester County Department of Health. This information will be shared only for public health purposes, which may include notifying close contacts of your child if they have been exposed to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your school community. Information about your child that may be shared includes your child’s name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name(s), teacher(s), enrollment and attendance, and after school or other program participation, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about your child will only be done in accordance with applicable law and the Port Chester School District’s policies protecting student privacy and the security of your child’s data.

Please take a few minutes to answer the questions below regarding testing and answer the final question whether you are willing to provide consent for your child/children to participate.

Please fill out a separate form for every child you have in the district.

Having consent in advance will enable us to quickly begin the testing process when it is mandated by the state.


Thank you, and stay safe!
Sign in to Google to save your progress. Learn more
What is your first name? (the first name of the person completing this form) *
What is your last name? (the last name of the person completing this form) *
What is your address? *
What is your preferred phone number? *
What is your best contact email? *
What is your child's first name? (please complete a separate form for each of your children) *
What is your child's last name? (please complete a separate form for each of your children) *
What is your child's date of birth? *
MM
/
DD
/
YYYY
What is your child's age in years? *
What is your child's gender? *
What is your child's ethnicity? *
What is your child's race? *
What grade is your child in? *
What school does your child attend for in-person learning? *
My child is signed up to receive healthcare at an Open Door School Based Health Center...
Clear selection
Please review the following information and provide your consent below.
I understand that New York State law allows some information about my child to be shared with and among certain County and New York State agencies (e.g., NYS Department of Health, Westchester County Health Department, Contracted Service Providers for COVID-19 Testing). This information will be shared only for public health purposes, which may include notifying close contacts of my child if they have been exposed to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your school community. Information about my child that may be shared includes my child’s name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name(s), teacher(s), enrollment and attendance, and after school or other program participation, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about my child will only be done in accordance with applicable law and the Port Chester Public School District’s policies protecting student privacy and the security of my child’s data.

● I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
● I consent for my child to be tested for COVID-19.
● I understand that my child may be tested more than once through June 30, 2021, and I understand I will be notified each time before my child is tested.
● I understand that this consent form will be valid through June 30, 2021, unless I notify the designated contact person from my child’s school in writing that I revoke my consent.
● I understand that my child’s test results and other information may be disclosed as permitted by law.
● I acknowledge that a positive test result will require my child to be sent home from school and remain at home until he/she meets the criteria to return to school according to state and local guidelines.
● I understand that this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action regarding my child’s health and medical care as well as in response to any test results.
● I understand that if I am a student age 18 or older, or may otherwise legally consent for my own health care, references to “my child” refer to me and I may sign this form on my own behalf.
I have read this COVID-19 testing consent form and know the contents thereof; that the same are true to our own knowledge and have given the answers set forth above knowing that the Port Chester School District will rely upon them as confirmation that the above-identified student, has/has not been granted consent for the district to perform COVID-19 testing. I agree: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Port Chester-Rye Union Free School District. Report Abuse