Student 𝐂𝐎𝐍𝐒𝐄𝐍𝐓 𝐅𝐎𝐑𝐌 𝐅𝐎𝐑 𝐂𝐎𝐕𝐈𝐃-𝟏𝟗 𝐓𝐄𝐒𝐓𝐈𝐍𝐆

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🅾🆅🅴🆁🆅🅸🅴🆆

𝐖𝐡𝐚𝐭 𝐢𝐬 𝐭𝐡𝐢𝐬 𝐟𝐨𝐫𝐦?
We are seeking your consent to test your child for COVID-19 infection. Hillside School District No. 93 (“School District”) has partnered with the University of Illinois (“Testing Partner”) to test School District students, teachers, and staff members for COVID-19 infection using the University of Illinois’ rapid rtPCR test (“SHIELD Test”). 𝐓𝐡𝐢𝐬 𝐭𝐞𝐬𝐭 𝐢𝐬 𝐜𝐨𝐦𝐩𝐥𝐞𝐭𝐞𝐥𝐲 𝐯𝐨𝐥𝐮𝐧𝐭𝐚𝐫𝐲 𝐚𝐧𝐝 𝐰𝐢𝐥𝐥 𝐧𝐨𝐭 𝐛𝐞 𝐚𝐝𝐦𝐢𝐧𝐢𝐬𝐭𝐞𝐫𝐞𝐝 𝐮𝐧𝐥𝐞𝐬𝐬 𝐭𝐡𝐢𝐬 𝐟𝐨𝐫𝐦 𝐢𝐬 𝐬𝐢𝐠𝐧𝐞𝐝.

𝐇𝐨𝐰 𝐨𝐟𝐭𝐞𝐧 𝐰𝐢𝐥𝐥 𝐲𝐨𝐮𝐫 𝐜𝐡𝐢𝐥𝐝 𝐛𝐞 𝐭𝐞𝐬𝐭𝐞𝐝?
Your child will be tested at least 1 time per week. All students will are eligible to participate in the unobserved testing. Students will be provided with the testing kits to bring home.

𝐖𝐡𝐚𝐭 𝐢𝐬 𝐭𝐡𝐞 𝐭𝐞𝐬𝐭?
If you consent, your child will receive a free SHIELD Test, which is an rtPCR screening test for the COVID-19 virus conducted by collecting saliva (spit).

𝐇𝐨𝐰 𝐰𝐢𝐥𝐥 𝐈 𝐤𝐧𝐨𝐰 𝐢𝐟 𝐦𝐲 𝐜𝐡𝐢𝐥𝐝 𝐭𝐞𝐬𝐭𝐬 𝐩𝐨𝐬𝐢𝐭𝐢𝐯𝐞?
The University of Illinois will provide all test results to the School District. If your student’s results are positive, you will be contacted by the School District. You will not be contacted if your student’s results are negative.

𝐖𝐡𝐚𝐭 𝐬𝐡𝐨𝐮𝐥𝐝 𝐈 𝐝𝐨 𝐰𝐡𝐞𝐧 𝐈 𝐫𝐞𝐜𝐞𝐢𝐯𝐞 𝐦𝐲 𝐜𝐡𝐢𝐥𝐝’𝐬 𝐭𝐞𝐬𝐭 𝐫𝐞𝐬𝐮𝐥𝐭𝐬?
If your child’s test results are positive, please contact your child’s doctor immediately to review the test results and discuss next steps. Your child must quarantine consistent with guidance from the Illinois Department of Public Health.

If your child’s test results are negative, this means that the COVID-19 virus was not detected in your child’s saliva (spit). Tests sometimes produce incorrect negative results called “false negatives” in people who have COVID-19. If your child tests negative but has symptoms of COVID-19, or if you have concerns about your child’s exposure to COVID-19, you should call your child’s doctor and quarantine consistent with the guidance from the Illinois Department of Public Health.

𝐖𝐡𝐨 𝐰𝐢𝐥𝐥 𝐫𝐞𝐜𝐞𝐢𝐯𝐞 𝐦𝐲 𝐜𝐡𝐢𝐥𝐝’𝐬 𝐭𝐞𝐬𝐭 𝐫𝐞𝐬𝐮𝐥𝐭𝐬?
Testing results will be available to any employees of the School District with a legitimate educational interest, consistent with the Illinois School Student Records Act. Additionally, the School District will share the following information in the manner described below:

Email *

𝐃𝐈𝐒𝐂𝐋𝐎𝐒𝐔𝐑𝐄 𝐎𝐅 𝐏𝐑𝐎𝐓𝐄𝐂𝐓𝐄𝐃 𝐈𝐍𝐅𝐎𝐑𝐌𝐀𝐓𝐈𝐎𝐍

The School District will share the following with the Illinois Department of Public Health and the Cook County Health Department: your student’s positive and negative test results, name, date of birth, sex, race, ethnicity, and address. The purpose of this disclosure is to facilitate contact tracing and for reporting purposes.

• The School District will share the following with the University of Illinois: your student’s specimens, positive and negative test results, name, date of birth, address, sex, student identification number, email address, mobile phone, school, race, and ethnicity. The purpose of this disclosure is to facilitate test processing and results, billing, contact tracing, and tracking of test usage.
• The School District will share positive and negative test results and student identifying information as otherwise required by law or guidance.
• All positive and negative test results will also be shared with the student’s parent/guardian for the purpose of seeking additional medical treatment.

𝐈𝐍𝐅𝐎𝐑𝐌𝐄𝐃 𝐂𝐎𝐍𝐒𝐄𝐍𝐓, 𝐀𝐂𝐊𝐍𝐎𝐖𝐋𝐄𝐃𝐆𝐌𝐄𝐍𝐓 𝐀𝐍𝐃 𝐀𝐒𝐒𝐔𝐌𝐏𝐓𝐈𝐎𝐍 𝐎𝐅 𝐑𝐈𝐒𝐊

I knowingly and voluntarily assume all risks related to my child’s participation in the SHIELD Test. I know that the SHIELD test may have a false positive or false negative result.

𝐂𝐎𝐍𝐒𝐄𝐍𝐓

By signing below, I attest that:
• I understand that my child may be tested multiple times through June 30, 2023, and that testing will occur at least 1 time per week.
• I understand that this consent form will be valid through June 30, 2023, unless I notify the designated contact person from my child’s school in writing that I revoke my consent.
• I understand and consent to the release of my child’s information consistent with the section above “Who Will Receive My Child’s Test Results?”

𝘽𝙮 𝙨𝙞𝙜𝙣𝙞𝙣𝙜 𝙗𝙚𝙡𝙤𝙬, 𝙄 𝙖𝙩𝙩𝙚𝙨𝙩 𝙩𝙝𝙖𝙩: 𝙄 𝙪𝙣𝙙𝙚𝙧𝙨𝙩𝙖𝙣𝙙 𝙩𝙝𝙖𝙩 𝙢𝙮 𝙘𝙝𝙞𝙡𝙙 𝙢𝙖𝙮 𝙗𝙚 𝙩𝙚𝙨𝙩𝙚𝙙 𝙢𝙪𝙡𝙩𝙞𝙥𝙡𝙚 𝙩𝙞𝙢𝙚𝙨 𝙩𝙝𝙧𝙤𝙪𝙜𝙝 June 30, 2023, 𝙖𝙣𝙙 𝙩𝙝𝙖𝙩 𝙩𝙚𝙨𝙩𝙞𝙣𝙜 𝙬𝙞𝙡𝙡 𝙤𝙘𝙘𝙪𝙧 𝙖𝙩 𝙡𝙚𝙖𝙨𝙩 1 𝙩𝙞𝙢𝙚 𝙥𝙚𝙧 𝙬𝙚𝙚𝙠. 𝙄 𝙪𝙣𝙙𝙚𝙧𝙨𝙩𝙖𝙣𝙙 𝙩𝙝𝙖𝙩 𝙩𝙝𝙞𝙨 𝙘𝙤𝙣𝙨𝙚𝙣𝙩 𝙛𝙤𝙧𝙢 𝙬𝙞𝙡𝙡 𝙗𝙚 𝙫𝙖𝙡𝙞𝙙 𝙩𝙝𝙧𝙤𝙪𝙜𝙝 June 30, 2023, 𝙪𝙣𝙡𝙚𝙨𝙨 𝙄 𝙣𝙤𝙩𝙞𝙛𝙮 𝙩𝙝𝙚 𝙙𝙚𝙨𝙞𝙜𝙣𝙖𝙩𝙚𝙙 𝙘𝙤𝙣𝙩𝙖𝙘𝙩 𝙥𝙚𝙧𝙨𝙤𝙣 𝙛𝙧𝙤𝙢 𝙢𝙮 𝙘𝙝𝙞𝙡𝙙’𝙨 𝙨𝙘𝙝𝙤𝙤𝙡 𝙞𝙣 𝙬𝙧𝙞𝙩𝙞𝙣𝙜 𝙩𝙝𝙖𝙩 𝙄 𝙧𝙚𝙫𝙤𝙠𝙚 𝙢𝙮 𝙘𝙤𝙣𝙨𝙚𝙣𝙩. 𝙄 𝙪𝙣𝙙𝙚𝙧𝙨𝙩𝙖𝙣𝙙 𝙖𝙣𝙙 𝙘𝙤𝙣𝙨𝙚𝙣𝙩 𝙩𝙤 𝙩𝙝𝙚 𝙧𝙚𝙡𝙚𝙖𝙨𝙚 𝙤𝙛 𝙢𝙮 𝙘𝙝𝙞𝙡𝙙’𝙨 𝙞𝙣𝙛𝙤𝙧𝙢𝙖𝙩𝙞𝙤𝙣 𝙘𝙤𝙣𝙨𝙞𝙨𝙩𝙚𝙣𝙩 𝙬𝙞𝙩𝙝 𝙩𝙝𝙚 𝙨𝙚𝙘𝙩𝙞𝙤𝙣 𝙖𝙗𝙤𝙫𝙚 “𝙒𝙝𝙤 𝙒𝙞𝙡𝙡 𝙍𝙚𝙘𝙚𝙞𝙫𝙚 𝙈𝙮 𝘾𝙝𝙞𝙡𝙙’𝙨 𝙏𝙚𝙨𝙩 𝙍𝙚𝙨𝙪𝙡𝙩𝙨?”. 𝙄 𝙖𝙜𝙧𝙚𝙚 𝙩𝙝𝙖𝙩 𝙞𝙛 𝙢𝙮 𝙨𝙩𝙪𝙙𝙚𝙣𝙩’𝙨 𝙎𝙃𝙄𝙀𝙇𝘿 𝙏𝙚𝙨𝙩 𝙧𝙚𝙨𝙪𝙡𝙩𝙨 𝙖𝙧𝙚 𝙥𝙤𝙨𝙞𝙩𝙞𝙫𝙚, 𝙢𝙮 𝙨𝙩𝙪𝙙𝙚𝙣𝙩 𝙬𝙞𝙡𝙡 𝙦𝙪𝙖𝙧𝙖𝙣𝙩𝙞𝙣𝙚 𝙘𝙤𝙣𝙨𝙞𝙨𝙩𝙚𝙣𝙩 𝙬𝙞𝙩𝙝 𝙩𝙝𝙚 𝙜𝙪𝙞𝙙𝙖𝙣𝙘𝙚 𝙛𝙧𝙤𝙢 𝙩𝙝𝙚 𝙄𝙡𝙡𝙞𝙣𝙤𝙞𝙨 𝘿𝙚𝙥𝙖𝙧𝙩𝙢𝙚𝙣𝙩 𝙤𝙛 𝙋𝙪𝙗𝙡𝙞𝙘 𝙃𝙚𝙖𝙡𝙩𝙝. *

YES

𝙉𝙖𝙢𝙚 𝙤𝙛 𝘾𝙝𝙞𝙡𝙙 (𝙧𝙚𝙣)/𝙎𝙩𝙪𝙙𝙚𝙣𝙩(𝙨). 𝙋𝙡𝙚𝙖𝙨𝙚 𝙩𝙮𝙥𝙚 𝙞𝙣 𝙩𝙝𝙚 𝙣𝙖𝙢𝙚𝙨 𝙤𝙛 𝘼𝙇𝙇 𝙤𝙛 𝙩𝙝𝙚 𝙨𝙩𝙪𝙙𝙚𝙣𝙩𝙨 𝙖𝙩𝙩𝙚𝙣𝙙𝙞𝙣𝙜 𝙃𝙞𝙡𝙡𝙨𝙞𝙙𝙚 𝙎𝙘𝙝𝙤𝙤𝙡.

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Name of Parent/Guardian

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