GJPS COVID-19 Symptomatic Rapid Test Kit Request Form
January 2022

Gahanna-Jefferson Public Schools (GJPS) has a limited number of BinaxNOW COVID-19 Home Tests to identify students and staff with a positive case of COVID-19. Due to low inventory of these tests nationwide, our supply of tests is limited to only GJPS staff and students currently enrolled in GJPS schools who have symptoms of COVID-19.

The BinaxNOW Test is a 15-minute rapid antigen test used to detect an active COVID-19 infection. The test was developed by Abbott Laboratories and approved for use by the U.S Federal Drug Administration (FDA).

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ABOUT THE TEST KIT
The BinaxNOW Test is a 15-minute rapid antigen test used to detect an active COVID-19 infection. The test was developed by Abbott Laboratories and approved for use by the U.S Federal Drug Administration (FDA).

A trained telehealth professional guides the individual through the at-home self-test via video call.

The NAVICA mobile app downloaded to a smartphone or tablet, allows the individual to:
    •  Display their COVID-19 test result
    •  Review previously-stored COVID-19 test results
    •  Share results with organizations, employers, and schools to verify negative test results
    •  Positive test results are reported to ODH through the NAVICA mobile app.
PICK UP TIMES AND LOCATION
After completing this Rapid Test Kit Request Form, kits are available for pick up at the GJPS Administration Building, 160 S. Hamilton Road.  Please ring the bell inside the front door for service.

A confirmation email from GJPS WILL NOT be sent.

Requested kits are available for pick up Monday-Friday while supplies last:
9:00 - 11:00 a.m. and 1:00 - 2:30 p.m.

Request Form Must Be Completed in Advance of Pick Up
You may only request kits for:
    •  The number of students you have enrolled in Gahanna-Jefferson Public Schools in your household who are showing symptoms of COVID-19.

YOU MUST ADD INFORMATION FOR EACH TEST REQUESTED. When you are finished completing the information for each test requested, please read the terms and conditions and sign your name at the end of this form.

A confirmation email from GJPS WILL NOT be sent.

NOTE: Rapid Test Kits may only be picked up Monday - Friday, 9:00 - 11:00 a.m. and 1:00 - 2:30 p.m.
Email Address.     *
First Name (who is completing this form) *
Last Name (who is completing this form) *
Phone Number *
A limited number of test kits are ONLY available for current GJPS students and current GJPS staff members who have symptoms of COVID-19. How many total kits are you requesting? Please contact Central Office at (614) 471-7065 if you have more than 5 current GJPS students in your household with symptoms of COVIDS-19. *
Kit #1 is requested for a: *
Kit #1: First Name *
Kit #1: Last Name *
Kit # 1: School student or staff attends. *
Kit #2 is requested for a:
Clear selection
Kit #2: First Name
Kit #2: Last Name
Kit # 2: School student or staff attends.
Kit #3 is requested for a:
Clear selection
Kit #3: First Name
Kit #3: Last Name
Kit # 3: School student or staff attends.
Kit #4 is requested for a:
Clear selection
Kit #4: First Name
Kit #4: Last Name
Kit # 4: School student or staff attends.
Kit #5 is requested for a:
Clear selection
Kit #5: First Name
Kit #5: Last Name
Kit # 5: School student or staff attends.
Terms and Conditions for Distribution
Please carefully read and agree to the terms for distribution of COVID-19 rapid test kits. The full PDF file may be downloaded here:  https://docs.google.com/document/d/1zf7l4E5CaFsLmDkiMdqLRJ2zRnLm8aZTXWk5e0aj5uk/edit
Gahanna-Jefferson Public Schools Agreement for Voluntary Distribution and Use of COVID-19 Rapid Test
Gahanna-Jefferson Public Schools (GJPS) is pleased to partner with the Ohio Department of Health (ODH) to offer a limited number of VOLUNTARY at-home COVID-19 rapid test kits to identify students and staff who exhibit symptoms of COVID-19. The limited number of kits are only available to current GJPS students and current GJPS staff members who have symptoms of COVID-19.

The receipt and use of the Rapid Test is conditioned upon compliance with and agreement to the following terms and conditions:

The Rapid Tests received will be used for current Gahanna-Jefferson Public Schools students and GJPS staff who exhibit symptoms of COVID-19.

Positive results will be communicated to the student’s school nurse within 24 hours.

Students testing positive will follow isolation guidelines and not return to in-person school or school activities until they are permitted to do so. If you believe the test produced a false-positive result, the student must still follow isolation guidelines unless receiving a negative result from a non-rapid COVID-19 test (PCR).

On behalf of the Student, the undersigned parent(s) and/or guardian(s) assume all risks and use of the Rapid Test and release, discharge, waive, and agree not to sue for any and all liability, claims, damages, causes of action and/or demands against the Gahanna-Jefferson Public Schools Board of Education (“Board”), FCPH, ODH and their employees of every kind and nature which may arise from or in connection with such use. The undersigned further agrees to indemnify and hold harmless the Board, FCPH, ODH and their employees from any claim arising out of or related to use of the Rapid Test including, but not limited to, reasonable attorney fees.

By signing below, the undersigned acknowledges reading and understanding the above terms and conditions and voluntarily accepting them on behalf of himself/herself and the Student(s).

Agree to the terms.  NOTE: Rapid Test Kits may only be picked up Monday - Friday, 9:00 - 11:00 a.m. and 1:00 - 2:30 p.m. *
Please type your full name to act as your signature in agreement with the legal terms linked above. NOTE: Rapid Test Kits may only be picked up Monday - Friday, 9:00 - 11:00 a.m. and 1:00 - 2:30 p.m. *
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