Test to Stay and Symptomatic Testing Consent
Test to Stay and Symptomatic Testing Consent

By completing and submitting this form, I confirm that I am the appropriate parent, guardian, or legally authorized individual to provide consent and:

A. I authorize collection and testing of a sample from my child for COVID-19 at school. I understand that my child‘s school will determine which testing methods are offered to my child and will inform me of the services the school is administering prior to the start of, or any change to, the school’s COVID-19 testing program. By signing this form, I am consenting to any of the following testing methods for my child.

     i.      Individual testing on symptomatic individuals: for when individuals present symptoms at school (SaS)
     ii.     Individual testing on close contacts (Test to Stay): for asymptomatic close contacts will be required to be tested for at least two days out of the five days. The first test will occur on the day immediately after close contact notification. The second test will be alone on day 5. All individuals testing negative being allowed to remain at school.

B.   I understand that all sample types will be non-invasive, short nasal swabs or saliva samples.

C.   I understand that I will be notified about positive results of any individual test for COVID-19 performed on my child.

D.   I understand that there is the potential for a false positive or false negative COVID-19 test result, no matter the kind of testing being performed. Given the potential for a false negative, I understand that my child should continue to follow all COVID-19 safety guidance, and follow school protocols for isolating and testing in the event the student develops symptoms of COVID-19.

E.   I understand that staff administering all COVID-19 testing have received training on safe and proper test administration. I agree that neither the test administrator nor the North Collins Central School District, nor any of its trustees, officers, employees, or organization sponsors are liable for any accident or injuries that may occur from participation in the COVID-19 testing program.

F.   I understand that my child must stay home if feeling unwell. I acknowledge that a positive individual test result is an indication that my child must stay home from school, self-isolate, and continue wearing a mask or face covering as directed in an effort to avoid infecting others.

G.   I understand the school system is not acting as my child‘s medical provider, this testing does not replace treatment by my child‘s medical provider, and I assume complete and full responsibility to take appropriate action with regards to my child‘s test results. I agree I will seek medical advice, care and treatment from my child‘s medical provider if I have questions or concerns, or if their condition worsens.

H.   I understand that COVID-19 testing may create protected health information (PHI) and other personally identifiable information of my child, and such information will only be accessed, used, and disclosed in accordance with HIPAA and applicable law. Pursuant to 45 CFR 164.524(c)(3), I authorize and direct the testing provider to transmit such PHI to my child‘s school, the New York Department of Public Health.

 I.   I understand that authorizing these COVID-19 tests for my child is optional and that I can refuse to give this authorization, in which case, my child will not be tested.

J.   I understand that I can change my mind and cancel this permission at any time, but that such cancellation is forward-looking only, and will not affect information previously released. To cancel this permission for COVID-19 testing, I need to contact my child’s nurse.

I, the undersigned, have been informed about the COVID-19 test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19 for my child.

Yes, I agree for the following children to be tested.
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Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent/Guardian Email
Please provide the best phone number to reach you during the day, starting with the area code. *
Child's first name *
Child's last name *
Child's date of birth *
Child's Grade *
Electronic Signature Applied - I understand and acknowledge that by checking this box, I am confirming that I have read this entire form and that the information I have provided is true and accurate.  I intend for this to serve as my electronic signature and I am authorizing the District to rely on my electronic signature.  I understand and acknowledge that this electronic signature has the same legally binding effect as if I had placed my handwritten signature on a paper form. *
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