Harwood Union MHS (SY23) Annual COVID-19 Diagnostic Testing Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Consent is required for HUUSD staff to perform COVID-19 testing of students or staff. To provide consent for such testing in the 2022-2023 school year, parents/guardians (for testing of students), students 18 years or older (for testing of themselves), or staff (for testing of themselves) must complete this form.

NOTIFICATION OF INFORMATION SHARING

The information about positive test results will be reported to the Vermont Department of Health as required by statute.

The Vermont Department of Health will report data they receive about all COVID-19 cases on their website (https://www.healthvermont.gov/covid-19/covid-19-data). No personally identifiable details are shared publicly.

The following information is required when reporting a COVID-19 positive test result to the Vermont Department of Health.

Name
Date of Birth
Sex
Race & Ethnicity
Parent/Guardian Name (if under 18)
Address & Phone Number
Date of start of symptoms and/or positive test result; type of test conducted

Please complete this form to grant permission for this testing to occur. If you wish to revoke this consent at any time, please contact your school nurse in writing.

Email *

Is this form being completed as the parent/guardian of a STUDENT or as a STAFF member *

Parent/guardian of a student

Student 18 years or older

Staff

Clear form

Never submit passwords through Google Forms.

This form was created inside of Harwood Unified Union School District. Report Abuse

Forms