COVID Weekly Testing Affirmation Report Form 2021-2022 School Year
According to our records, you are unvaccinated for COVID-19.  Therefore, pursuant to 10 NYCRR 2.62 and the NYSDOH Commissioner of Health, you are required to submit to weekly testing.  The District will make this form available to staff on a weekly basis and I ask that you complete the form only if you have tested for the upcoming work week.

If you are tested at Orleans/Niagara BOCES or its component Districts (NWCSD etc.) the results will be automatically sent to our office.  You will be notified only if you have a positive result.

If you are tested at any other facility, you are required to submit proof of a negative test by no later than Wednesday morning before Noon directly to Barb LaDuca or Heidi Dashnaw by fax or scanned in an email, we may be flexible depending on results.  Should you need additional time, please contact Tom Stack at 215-3009 immediately.  If you test positive, please notify our office immediately.  In addition, please call our office if testing results are delayed.

PLEASE NOTE:  You are not required to receive the vaccine at this time.  Providing this information is not a violation of HIPPA but will be kept confidential.

If you are vaccinated in the future, you are required to report that status to our office.  You must also submit proof of your vaccination status.  You must continue to test weekly until full vaccination status has been reached.

*You must comply with the testing requirement in order to work in a school setting.  This testing will be done on your own time and when possible the District may be able to assist with the facilitation of testing.  

*Note: There is currently no NYS paid leave time for Covid-19 testing.

If you have any questions, please feel free to contact me by email or by phone at 215-3009.   Thank you for your compliance.  

Please respond to report your vaccination status by completing this form.
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Email *
What building is your primary work location? *
Last Name *
First Name *
Your Phone Number *
Date Tested *
MM
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DD
/
YYYY
Testing Location *
Name Of Testing Location If Other is selected above. *
Thank you for completing this form.  Please remember to click the "SUBMIT" button below!  If you have any questions, please contact our office at the numbers listed below.  
Tom Stack:  215-3009
Barb La Duca:  215-3006
Heidi Dashnaw: 215-3005


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