Ages 15-19: COVID-19 Weekly Testing Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

A minor 15 years of age or older may consent to COVID-19 testing as ordered by
the Oregon Health Authority under ORS 109.640(2)(a).

The form needs to be completed by the student.

Student first name: *

Student last name: *

Email address: *

Home address: *

City: *

Zip code: *

County: *

Date of birth: *

YYYY

School: *

Grade level *

Consent

By completing this form electronically, I confirm that I am consenting to once a week screening testing for COVID-19 during the 2021-2022 academic school year.

I understand that COVID-19 testing is optional and that I may refuse to give consent, in which case, I will not be tested.

I understand that my school may require me to say home from school if I am feeling unwell.

I understand that an independent laboratory acting on behalf of my school will conduct the weekly screening testing. I understand that in order for weekly screening testing to be performed at an independent laboratory, certain personal information will need to be communicated to the laboratory for purposes of administering the program, and only to the extent necessary to administer the program, including my name, date of birth, and school cohort.

I understand that the Oregon Health Authority (OHA) has made these tests available through a standing order. I understand that neither OHA or the school is acting as my healthcare provider and that this testing does not replace treatment by my healthcare provider. I assume complete and full responsibility to take appropriate action regarding my test results, which means to seek medical advice, care, and treatment from a health care provider if necessary, or to speak with my parent and/or guardian if I need help understanding what to do after receiving my test results.

While the COVID-19 PCR test offered by the lab is considered the most accurate type of test, I understand that there is a possibility of false negative test results and that I could still be infected with COVID-19 even if the test result is negative. I also understand that if I test positive for COVID-19, the test result will be reported to the local public health authority as required by law. If I test positive, my parent and/or guardian may be informed of my results under ORS 109.650.

Personal health information will not be released without written consent except when required by law.

I give my permission to participate in weekly screening testing for COVID-19.

Signature of student (please type name) *

Date: *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Bethel School District. Report Abuse

Forms