STUDENT CONSENT FORM FOR VOLUNTARY COVID-19 TESTING
The South Carolina Department of Health and Environmental Control (DHEC) takes the health and safety of students and school staff very seriously. As such, DHEC is partnering with schools to provide voluntary PreK-12 COVID-19 testing for students and school staff.

What is the test?

If you consent, your child will be tested for COVID-19 using the Abbott Laboratories BinaxNOW rapid antigen test. The Abbott BinaxNOW rapid antigen test is a test that indicates if someone currently has COVID-19. A school nurse (RN or LPN) or athletic trainer who has been trained to administer this test will either collect the specimen or will instruct and supervise as the sample is self-collected. To collect the specimen, a swab, similar to a Q-Tip, is placed inside the nostril approximately ½ of an inch deep and rotated against the nostril wall. This is
done in each nostril and only takes 10-15 seconds. The results will be ready in approximately 15 minutes. Safety precautions will be followed prior to, during, and after the test including all proper use of personal protective equipment (PPE), hand hygiene, and cleaning and disinfection of the environment.

TO BE COMPLETED BY PARENT, GUARDIAN, LEGAL CUSTODIAN, FOSTER CARE PROVIDER, STUDENT OVER THE AGE OF 16 OR STUDENT OTHERWISE AUTHORIZED TO PROVIDE CONSENT
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Parent/Guardian/Legal Custodian/Foster Care Provider Information
Parent's Name: First, Last *
Address: *
Telephone Number: *
Email Address: *
Student Information
Student First Name: *
Student Last Name: *
Grade Level: *
Student Date of Birth: *
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Student Address: *
CONSENT
By signing below, I attest that:
• I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
• I authorize the school nurse, RN or LPN, or the athletic trainer to conduct or supervise the specimen collection and BinaxNOW testing procedure for COVID-19 through anterior nasal swab for my child as ordered by an authorized DHEC medical provider.
• I understand that by providing consent for my child to be tested, I am also authorizing the test result and testing records to be disclosed to DHEC, school contact tracing staff, and Clinical Laboratory Improvements Amendments’ inspectors as applicable.
• I understand that the school, school district, school staff, DHEC, and DHEC’s medical providers are not acting as my child’s
medical provider. This testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action with regard to the test result.
• I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
• I acknowledge that a positive test result requires my child to isolate and not come to school for the applicable period of time following a positive test.
I understand that this consent form will be valid for either: (please check one) *
Povinné
I understand that if I elect to allow this consent form to be used for the 2020-2021school year, I will notify my child’s school in writing if I choose to revoke my consent.• I understand that if I am a student age 16 or older, or a student who may otherwise legally consent for my own health care, references to “my child” refer to me and I may sign this form on my own behalf.
eSignature of Parent/Guardian/Legal Custodian/Foster Care Provider: (if child is under the age of 16).  Type full name below. *
Date: *
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eSignature of Student: (Type name below) *
Date: *
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