IRCSD COVID-19 Testing/Screening Consent for Staff 2021-22
*PLEASE NOTE* If you DO NOT CONSENT to having nursing staff conduct a rapid test for COVID-19 on you, there is no need to complete this form.

Please fill out a separate form for each staff member.

This form will give Indian River Central School District permission to screen you for COVID-19 by performing a simple, non-invasive COVID-19 rapid test. This consent is separate from the earlier request related to potential yellow-designation testing of 20% of the population.

In this case, COVID-19 testing will be performed by IRCSD nursing staff for screening and/or on-demand/as needed. If a staff member is seen in the nurse's office after developing symptoms of COVID-19, the school nurse will ask for final permission prior to performing the test.  (It is important to note that staff members should NOT report to school with symptoms, but we do realize that symptoms do sometimes appear during the school day.)

This form will be used for the 2021-22 school year and will expire on June 30, 2022.
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First Name *
Last Name *
School Building *
Street Address *
City *
Zip Code *
County *
Phone Number *
Date of Birth *
Age *
Gender *
Race *
Electronic Signature Consent
I consent to be screened for COVID-19 at school.

By selecting "I APPROVE" below, I attest that:
*I have signed this form freely and voluntarily.
*I understand that this consent form will be valid through June 30, 2022, unless I revoke such consent in writing.
*I understand that my test results and other information may be disclosed as permitted by law.
*I understand that should I test positive for COVID-19, I will not be permitted to return to school until I meet the Jefferson County Health Department criteria for returning to school.
Electronic Signature *
Please type your full name.
Date *
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