COVID-19 Testing Consent Form

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The purpose of this form is to provide consent for school nurses to test students and staff in school in the event that our school district is deemed to be in a Yellow Zone. We will notify you if/when this announcement is made.

As part of the Governor's Cluster Action Initiative to monitor COVID-19 spread, the New York State Department of Health (NYSDOH) requires schools providing in-person instruction in “Yellow Zones” to test 20% of in-person students, teachers and staff for COVID-19, at least once a week while the school remains in a designated yellow zone.

Please note that we would not conduct any testing without advance notice, and parents can be present during the test if they wish. Tests will be non-invasive, rapid screening tools. A non-invasive BinaxNOW nasal swab sample will be collected by our school health personnel. There will be no cost for these tests. Only students whose parent/guardian has provided this signed consent form to school will be tested.

Please submit one consent form per in-person learner/staff member.

Email *

Student/Staff Name *

Please indicate your role to the person to be tested.

Parent/Guardian

Self (Staff Members Only)

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Date of Birth *

YYYY

Gender *

Female

Male

Prefer not to say

Other:

Address *

Phone Number *

Grade/Position *

The law requires and/or allows some information about your child to be shared with Schenectady County and New York State Public Health Agencies. This includes notifying Schenectady County Public Health Services about the COVID-19 results of each student who is tested, including the student’s name, date of birth, other identifying information, and result of the COVID-19 test.

● I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
● I authorize the Duanesburg Central School District to test my child for COVID-19 infection.
● I understand that my child may be tested at multiple times during the 2020-2021 school year.
● I understand that this consent form will be valid through June 30, 2021, unless I revoke such consent in writing.
● I authorize my child’s test results and other information to be disclosed to any governmental entity as may be required or permitted by law.
● I acknowledge that a positive test result will require my child to be sent home from school and remain at home until they meet the criteria to return to school according to the Schenectady County Department of Public Health.
● I understand that this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action regarding my child’s test results. I agree that I will seek medical advice, care, and treatment for my child from his/her medical provider if I have questions or concerns or if I become ill or my condition worsens.
● I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

I give permission for my child's school to collect a sample and test my child using a BinaxNOW COVID-19 test. *

I give permission

I do not give permission

Please write your name here to indicate your electronic signature. *

A copy of your responses will be emailed to the address you provided.

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