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Attestation of At-Home Rapid COVID-19 Test Result
Attestation of At-Home Rapid COVID-19 Test Result
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* Indicates required question
Email
*
Your email
I attest that the at-home/ over-the-counter rapid COVID-19 test described below was performed on:
*
Yes
No
Student or Staff’s Name (Last, First)*
*
Your answer
The test was administered on the individual and the results belong to the test performed on them. The test was performed following the instructions provided by the test kit.
*
Yes
No
Required
Student/Staff's Date of Birth:
*
MM
/
DD
/
YYYY
School:
*
STC
APC
Required
Grade (if applicable):
Your answer
Teacher (if applicable):
Your answer
Date and Time Tested:
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Brand of Home Test:
*
Your answer
Serial Number on Test Packaging:
*
Your answer
Test Result as Observed by the Parent or Designated Adult Who Performed the Test (check one):
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Positive
Negative
Unable to Determine
Test Performed By Name (Last, First)
*
Your answer
Parent or Legal Guardian (if different than above):
Your answer
Phone
*
Your answer
Date Submitted:
*
MM
/
DD
/
YYYY
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