Canajoharie Central School District - COVID-19 Testing Consent Form
The Governor's Cluster Action Initiative and the NYS Department of Health requires schools providing in-person instruction to test specific percentages of in-person students, teachers, and staff for COVID-19 if the school is in a designated Yellow, Orange, or Red zone, in order to hold in-person teaching. There are two kinds of tests for COVID-19: the PCR test and the antigen test (also known as a rapid test). Both tests require a specimen (sample) be collected (taken) form the person being tested. The sample is then tested to find out if the person has COVID-19. How a sample is collected depends on the type of test being used. We are using a BINAX-NOW rapid test.

Only Students whose parents/guardians have provided this signed consent form to the school will be tested:

-A sample will be collected from your child by trained health personnel.
-The following type of sample that will be collected at school is the Nasal Swab (front/sides of nose), collected by trained healthcare personnel.
-The test is non-invasive, simple, and quick. The process will involve inserting a small swab, similar to a Q-Tip, into the front of the nose.
-Click the link to see how the test is administered and works: https://youtu.be/j3WCdN8Ey6A
-Once a sample is collected, the test is done to determine the results.
-Please submit the form to be considered for testing by Sunday, December 20, 2020.
-Our school will be collecting samples and doing the COVID-19 test at school using the BINAX-NOW Test
Student First Name *
Student Last Name *
Date of Birth *
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Gender *
Address *
City *
State *
Zip *
Phone - include area code - 518-xxx-xxxx *
Grade *
I give permission for my child's school to: *
I understand the school will notify me if my child's test is negative by a letter sent home with my child and if my child is positive, a phone call will be made. I also understand that my child's test results and other information may be disclosed as permitted by law. *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Date *
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Submit
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