Consent for COVID-19 Testing (Student Surveillance)

*Field is Required

Date:

Student Name:

Date of Birth:

Erie 1 BOCES School:

Please Choose One of the Following:

Please carefully read the following informed consent, and sign below:

1.	I understand that in accordance with Commissioner’s Determination on Covid-19 Testing pursuant to 10 NYCRR 2.62, Erie 1 BOCES is required to offer COVID-19 screening testing to students on a weekly basis in certain geographic areas. Informed written parental consent is required prior to performing COVID-19 testing on any minor student under the age of 18, and informed written student consent for testing is required for testing any student 18 years of age and older. By signing below, I authorize a member of Erie 1 BOCES’ school health staff or other authorized trained individual to conduct weekly collection of samples on me/my child through a nasal swab test (front/sides of nose), saliva swab of mouth (or a self-swab monitored by Erie 1 BOCES’ school health staff, where applicable) and to weekly testing of the sample for COVID-19 infection by the foregoing individual or by an outside lab (including, but not limited to, “USA Medical”).

2.	I understand that this consent form will be valid from the date of my signature below through June 30, 2022, unless I revoke such consent in writing.

3.	I understand that I will be notified in the event I/my child test positive, and that information about my/my child’s testing may need to be shared with the Erie County Department of Health, the New York State Department of Health, or other governmental agency. This information may include my/my child’s name, date of birth, race/ethnicity, gender, address, phone number, and COVID-19 test results. By signing below, I authorize my/my child’s test results and other related personally identifiable information to be disclosed to Erie 1 BOCES and to any county, state, or other governmental entity as may be required by applicable law, regulation, order, directive, or determination. I acknowledge that sharing of this information will only be done in accordance with applicable law and regulation and Erie 1 BOCES’ policies protecting privacy and security of student medical information. This information may also be shared with component school districts as may be required to ensure coordination of compliance with Commissioner’s Determination on Covid-19 Testing pursuant to 10 NYCRR 2.62. It may also be shared with such districts and/or other applicable entities or individuals as directed for contract tracing purposes.

4.	I acknowledge that a positive test result will require that I/my child be sent home from school (or not be allowed to return to school) and to remain at home until I/my child meets the criteria to return to school according to ECDOH, NYSDOH, and any other applicable guidelines, and to abide by Erie 1 BOCES' protocols for isolation and/or quarantine as well as all applicable federal, state, and/or local directives on isolation and/or quarantine, to avoid infecting others.

5.	I understand that by consenting to this testing, I am not creating a patient relationship between me/my child and Erie 1 BOCES or any of its staff members. I understand that Erie 1 BOCES is not acting as my/my child’s medical provider, that this testing does not replace treatment by my/my child’s medical provider. I assume complete and full responsibility to take appropriate action regarding my/my child’s test results and will contact my/my child’s medical provider immediately to review the test results if I/my child tests positive for COVID-19. I agree that I will seek medical advice, care, and treatment from my/my child’s medical provider if I have questions or concerns or if I/my child becomes ill or my/his/her condition worsens.

6.	As with any medical test, I understand that there is the potential for a false positive or false negative COVID-19 test result.

I, the undersigned, by signing and submitting this form, confirm that I have been informed about the 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 have signed this form freely and voluntarily and I am legally authorized to make such medical decisions on my/my child’s behalf.

Type Name of Person Completing this form to Authorize Consent

Relationship to Student

By typing in my full name above, and clicking “Submit,” I hereby acknowledge and agree that it is my intent both to sign and to submit this Informed Consent document electronically. I understand that my signing and submitting this document in this fashion is the legal equivalent of having placed my handwritten signature on the submitted document.