By completing and submitting this form, I confirm that I am the appropriate individual to provide consent and:

A. I authorize the collection and testing of a weekly pooled COVID-19 test on me during school hours, in addition to any necessary individual diagnostic follow-up tests (including Abbott BinaxNOW rapid antigen tests and PCR/molecular tests). I understand that all sample types will be non-invasive, short nasal swabs.

B. I understand that pooled testing does not yield individual results for each member of a pool, and that the results of my individual results within a pooled test cannot be shared with me. However, I understand that my personal health information and personally identifiable information may be entered into the testing provider’s technology platform to assist with tracking pooled testing and identifying individuals in need of follow-up testing.

C. I understand that I will be notified about the results of any individual diagnostic “follow-up” test for COVID-19 performed on me.

D. I understand that there is the potential for a false positive or false negative COVID-19 test result for pooled or individual tests. Given the potential for a false negative, I understand that I should continue to follow all COVID-19 safety guidance, including mask-wearing and social distancing, and follow school protocols for isolating and testing in the event I develop symptoms of COVID-19.

E. I understand that staff administering pooled testing and follow-up testing have received training on  safe and proper test administration. I agree that neither the test administrator nor the Public Schools of Brookline, nor any of its trustees, officers, employees, or organization sponsors are liable for any accident or injuries that may occur from participation in the pooled testing program.

F. I understand that I must stay home if feeling unwell. I acknowledge that a positive individual follow-up test result is an indication that I must stay home from school, self-isolate, and continue wearing a mask or face covering as directed in an effort to avoid infecting others.

G. I understand the school system is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand I am financially responsible for any care I receive from my healthcare provider.

H. I understand that follow-up testing will create protected health information (PHI) and other personally identifiable information about me. Pursuant to 45 CFR 164.524(c)(3), I authorize and direct the testing provider to transmit such PHI to my school, the Department of Public Health, and the testing laboratory. I further understand that PHI may be disclosed to the Executive Office of Health and Human Services and any other party, as authorized under HIPAA.

I. For Students Only:  I understand that participation in pooled testing may require my school to disclose my identity, demographic, and contact information from education records to the testing provider and, for follow-up tests, will require the school to disclose my identity, demographic, and contact information from education records to the Department of Public Health.  Pursuant to FERPA, 34 CFR 99.30, I authorize my school to disclose such personally identifiable information (PII) as is required for my participation in pooled and follow-up testing.    

J. I understand that authorizing these COVID-19 tests is optional and that I can refuse to give this authorization, in which case, I will not be tested.

K. I understand that I can change my mind and cancel this permission at any time, but that such cancellation is forward-looking only, and will not affect information I already permitted to be released. To cancel this permission for COVID-19 testing, I need to contact the nurse at my school.

I acknowledge that I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.