USD 465 COVID-19 or COVID/Influenza Testing Consent Form
Consent and Testing information

The law allows some information about the staff member or student to be shared with the health department or KDHE. This information will be shared only for public health purposes. Information that may be shared with these agencies includes name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name(s), teacher(s), classroom/cohort/pod, enrollment and attendance history and after school or other program participation, names of other family members or guardians, address telephone, mobile number and email address. Sharing of information will only be done so in accordance with applicable law and school policies protecting student and staff member privacy and the security of their data.
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Patient First Name *
Patient Last Name *
Requested Test?
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What building is the patient most affiliated with? *
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