Informed Consent for COVID-19 pooled testing
Parents and staff MUST sign a consent form through the PowerSchool parent/teacher portal prior to receiving testing. Students and staff who have not completed the consent form will not be tested. If you are unable to access the portal, please contact your school nurse for a paper form. By authorizing testing, you are agreeing to the following:
I authorize the collection and testing of a weekly pooled COVID-19 test on myself/my child, in addition to any necessary individual diagnostic follow up tests. I understand that all sample types will be non-invasive, short nasal swabs. I authorize Patriot Medical Laboratories, dba CIAN Diagnostics, to conduct screening of pooled nasal samples for COVID-19 testing. In the event of a positive pool, I authorize individual testing of my/my child’s submitted sample as ordered by an authorized medical provider or public health official. I understand that a performing CLIA laboratory may use my/my child’s specimen and any testing performed on that specimen for research and development so long as the information has been de-identified pursuant to law.
I understand that pooled testing does not yield individual results for each member of a pool, and that the results of my/my child’s individual results within a pooled test cannot be shared with me. However, I understand that my/my child’s personal health 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.
I understand that I will be notified about positive results of any individual diagnostic “follow up” test for COVID-19 performed on myself or my student.
I acknowledge that results of screening tests alone are not sufficient to detect or rule out the possibility that an individual has been exposed to or is infected with COVID-19.
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/my student 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/my child develops symptoms of COVID-19.
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 Shrewsbury Public Schools, 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.
I understand that I/my child must stay home if feeling unwell. I acknowledge that a positive individual follow-up test result is an indication that I/my child must stay home from school, self-isolate, and continue wearing a mask or face covering as directed in an effort to avoid infecting others.
I understand that Shrewsbury Public Schools is not acting as my/my child’s 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/my child’s test results. I agree I will seek medical advice, care and treatment from my/my child’s medical provider if I have questions or concerns, or if my/my child’s condition worsens. I understand I am financially responsible for any care I/my child receives from my healthcare provider.
I understand that follow-up testing will create protected health information (PHI) and other personally identifiable information about my child. Pursuant to 45 CFR 164.524(c)(3), I authorize and direct the testing company to transmit such PHI to my school, the Department of Public Health, and the testing provider. 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 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 Karen Isaacson, COVID operations coordinator for Shrewsbury Public Schools, 508-841-8727. email@example.com
I certify that I have voluntarily provided my/my child’s fresh and unadulterated specimen for analytical testing. The identifying and contact information I have provided to the testing lab (via PowerSchool) are accurate.
I, the undersigned, 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 for myself/my child.
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