Consent For PCR Saliva Testing Westchester County Schools COVID-19 Screening Testing Program
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Student's Name *
Student's Grade *
Student's School *
Student's Address *
City/State *
Zip Code *
Student's Date of Birth *
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Student's Sex *
Student's Race (select all that apply): *
Required
Student's Ethnicity *
Has your child/you tested positive for COVID-19 in the last 90 days? *
If YES, date of positive test
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I authorize the Westchester County Department of Health, (the “WCDH”) and it contractors to
receive self-collected saliva samples on the above named individual and conduct COVID-19
screening tests on those samples.
● I have read and understand the attached Frequently Asked Questions about the Westchester
County Schools COVID-19 SCREENING TESTING PROGRAM (the “Program”). I understand
there will be no cost to me for this testing Program. I authorize the release of information as
indicated in the Frequently Asked Questions as part of the Program for public health purposes.
● By signing this, I am giving permission for my child/legal guardian or myself to participate in
this voluntary testing Program.
● I understand that I have the right to revoke this consent at any time by notifying in writing the
school nurse or whomever the school designates in writing to receive such notice.
● I understand that if my child/legal guardian/I have tested positive for COVID-19 within the last
90 days, my child/legal guardian/I will not be able to participate in the Program until 90 days
has passed since the positive test result.
● I understand and acknowledge that WCDH, its contractors, and the school/district are not
acting as the medical provider and this Program is not for testing if a person is sick or exposed
to a person with COVID-19. I will receive positive test results and will take appropriate actions.

I have read this form and all of my questions have been answered to my satisfaction. By signing this
form, I acknowledge that I have read and accept all of the above.
Signature of Student, Parent/Guardian if Student is under the age of 18
Print Name *
Parent/Guardian relation to Student if Student is under the age of 18 *
Parent/Guardian Telephone: if Student is under the age of 18 *
Date *
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Westchester County Schools COVID-19 Screening Testing Program Frequently Asked Questions
What is the purpose of this form?

The County of Westchester, acting through the County Department of Health (”WCDH”), is sponsoring the
Westchester County Schools COVID-19 Screening Testing Program (the “Program”) for all schools and school
districts in Westchester County. The WCDH is sponsoring the Program, along with its lab testing partners: Mount
Sinai Health Systems, Inc., Mirimus Inc. and Quadrant Biosciences, Inc. (“Testing Partners”) Your School District
has opted to participate in the Program, which is a FREE COVID-19 PCR saliva testing for our schools’ teachers,
students, and staff. You may reach out to Rosie Finizio, Westchester County Parent Liaison at 914-995-2501 or
RFinizio@westchestergov.com or your student’s school if you have any questions.

 This FAQ gives you information about the Program, including the process for testing, the benefits and
limitations of testing, how your private information will be protected, and the process for notifying you of
test results.
 The County’s Testing Partners are subject to federal and state laws that require them to maintain the
confidentiality of any personal information that you agree to give to them for the Program. Our Testing
Partners take very seriously their obligation to protect your information, and they will not use or disclose
your information other than as described herein, in the Authorization to Disclose Protected Health
Information Form and as required or permitted under law or regulation.
 The Program is subject to the County’s receipt of funding from the Health Research, Inc. and federal
Centers for Disease Control and Prevention to operate the Program.


What will happen once I consent to participate in this part of the Program?
 The County’s Testing Partners will test each saliva sample that they receive using testing platforms that
are used to test for COVID-19 in labs across the country.
 The Testing Partners will test each sample, either individually or in a group (pool) with other samples.
Group (pooled) samples that are positive for COVID-19 will then be tested individually to identify the
positive sample. When a positive result is found, the individual (or their parent/guardian) and the
individual’s school will be notified.

How does the testing process work?

● Once you give consent to participate in the Westchester County Schools COVID-19 Screening Testing
Program, your student will give a small sample of saliva for each designated testing event, and that
sample will be sent to a lab for testing. In most instances, saliva samples can be collected from the
comfort and privacy of the home using pre-distributed test kits. Samples will be returned by your Student
to the school on designated test days for transport to the labs. In some instances, saliva samples will be
given under the supervision of the County’s Testing Partners’ trained staff. In all cases, sample collection
events will be designed to protect the safety of all involved.
● If your student tests positive, you will be contacted with the result. The Testing Partners will also alert
specific members of the school’s staff who have been instructed on how to protect your confidential
information. These staff members will use test results only as necessary to prevent further spread within
the school (ex: the teacher to determine which classmates were exposed) and will never share your
Student’s name.

Why can’t my student/I be tested if my student/I tested positive for COVID-19 in the last 90 days?
 Individuals may continue to receive positive test results for up to 90 days after having COVID-19, even after
they have recovered from their symptoms and are no longer contagious. By removing people who had a
positive test result in the last 90 days from the testing program, we can avoid isolating people who are not
actually contagious.
 Once 90 days have passed since your student’s/your last positive COVID-19 test, your student/you will be
included in the testing program.

How will you maintain my privacy rights?

● The County’s Testing Partners are committed to protecting personal information, including your Student’s
test results, from inappropriate use, disclosure, or access. The law requires the County’s Testing Partners
to protect your student’s personal information and they take that obligation seriously.
● In some cases, the samples will be labeled only with a barcode, and there will not be any identifying
information (like your Student’s name) visible on the sample itself. If barcodes are not used and personal
information is written on the sample, testing personnel are trained to keep those samples confidential.
● Our Testing Partners and [district name] have agreed that your personal information will not be used or
disclosed in any way except as described in this consent form, the Authorization to Disclose Protected
Health Information Form, and as required or permitted under law or regulation.
● Our Testing Partners are required by law to notify government authorities of positive test results,
including basic demographic information about the individuals tested. The same personal information
requested on this form would be shared with the Department of Health by any doctor’s office or testing
center in the event of a positive result.
● Our testing partners have implemented strict physical and electronic protections against improper access
to personal information that it collects and maintains, and they will keep your student’s personal
information according to those strict protocols.

Are there any possible risks of the testing program?

● The testing creates no health risks. The saliva-based tests are non-invasive, painless, and quick.
● Although the testing platforms that our testing partners use are highly accurate, no COVID-19 test is
100% accurate, and it is possible that your screening test will result in a false positive or a false negative.
That means that if a screening test returns a positive result, it is possible that there is no COVID-19
infection, and if a screening test returns a negative result, it is possible that there is a COVID-19 infection.
● The results of screening tests alone are not sufficient to detect or rule out the possibility that an individual
has been exposed to or is infected with the virus that causes COVID-19. There is a possibility that a
screening test may produce false positive or false negative results.

What are the possible benefits of participating in the program?

● The Program is designed to help stop or slow the spread of COVID-19 in your school and beyond, by
identifying COVID-19 infections quickly and helping those who test positive to safely isolate until they are
well. By identifying COVID-19 infections quickly, before they have the chance to spread, the Program is
designed to provide a safer environment for everyone.
Authorization To Disclose Protected Health Information (COVID Test Results)
Student's Name *
Student's Address *
City/State *
Zip code *
Date of Birth *
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Telephone *
I authorize Westchester County Department of Health and its testing partners (Mount Sinai Health Systems, Inc.,Mirimus Inc. and Quadrant Biosciences, Inc.) to disclose the above named individual’s health information as follows:
Port Chester-Rye Union Free School District
113 Bowman Avenue
Rye Brook, NY 10573

Description of Information to be disclosed: The COVID-19 PCR SALIVA TEST RESULTS (“COVID Information”) of the
above named individual.
Purpose of Disclosure: PARTICIPATION IN WESTCHESTER COUNTY SCHOOLS COVID-19 SCREENING TESTING
PROGRAM and SCHOOL ATTENDANCE
This authorization will expire one year from the date on which it was signed.
This authorization permits the release of COVID information of the above-named individual to the above-named Recipient on
an ongoing basis for however many COVID tests such individual undergoes before the expiration of this authorization.

1. I understand that any disclosure/release is bound by the Health Insurance Portability and Accountability Act of 1997 (HIPAA)
45 C.F.R. pts 160 & 164; and re-disclosure of this information to a party other than one designated above is forbidden without
written authorization on my part, unless required or permitted under law or regulation.

2. I understand that the WCDH and its Testing Partners have no ability to prevent re-disclosure of my COVID information by
Recipient.

3. Signing this authorization is voluntary. I understand that I have the right to revoke this authorization at any time, except to
the extent that WCDH and its Testing Partners have already acted in reliance on it. I understand that if I revoke this
authorization, I must do so in writing and present my written revocation to the school nurse or whomever the school designates
in writing to receive such notice.

I have read this form and all of my questions have been answered to my satisfaction. By signing this form, I
acknowledge that I have read, understand and accept all of the above.
Signature of Student, Parent/guardian if Student is under the age of 18
Print Name *
Parent/Guardian relation to Student if Student is under the age of 18 *
Parent/Guardian address if Student is under the age of 18 *
Parent/ Guardian email address if Student is under the age of 18 *
Parent/Guardian Telephone: if Student is under the age of 18 *
Date *
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