Staff Consent Form: COVID-19 Pooled Testing

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To be completed by staff or students consenting for themselves.

You will not be notified of pooled test results, but you will be notified of individual follow up test results either via phone or email.

Click here to view the printable version of the form: https://5il.co/pj18

Email *

School: *

CPES

GES

BES

DHS

Greenhouse Program

Armory Program

Central Office

Other:

Full Name (Last name, First name): *

Cell/Mobile #: *

Date of Birth *

YYYY

Have you been diagnosed with COVID-19 in the past 90 days?: *

Yes, I have tested positive for COVID-19 in the past 90 days

No, I have not tested positive for COVID-19 in the past 90 days

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