COVID-19 Testing Consent Form

Harrison Central School District

COVID-19 Testing Consent Form
The Harrison Central School District is implementing several strategies to bring more students back for in-person instruction as soon as it is safe for students, faculty, and staff. One of these strategies involves conducting voluntary, non-invasive COVID-19 screening tests for 10% of our students, faculty and staff on a weekly basis.

The Westchester County Department of Health has approved Harrison’s request to conduct these screening tests, but we require your assistance. The District is seeking your advance consent for your child(ren) to participate in free COVID-19 testing provided at school by trained school nurses. If you have already provided consent, you do not need to provide consent again.

The scheduling of on-site COVID-19 screening tests will begin in early March and continue on a weekly basis, with a different 10% of our students and staff tested each week. The COVID-19 test is a minimally invasive nasal swab test that requires swabbing the inside of both nostrils (not the deep nasal swab test). Tests results are available in 15 minutes. Student participation in the testing requires parent/guardian consent. We encourage your participation so we can keep our schools open and make them safer. To see a brief video that demonstrates how the COVID-19 test is administered, click here.

To consent to COVID-19 testing for your child, please complete this consent form (you will need to complete a separate consent form for each child that attends Harrison schools). Your consent is valid for the 2020-21 school year. If you provide consent for testing, you will receive additional information about COVID-19 testing in the near future.

Please note that the information collected in this consent form is required by the New York State Department of Health for the District to participate in free COVID-19 testing.

Thank you for your partnership as we work to keep our school community healthy and safe.
Please select the choice that describes you.*

I am a parent/guardian completing this consent form for a child who attends Harrison schools in-person.I am a Harrison Central School District employee.
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Student Name*

First NameLast Name
Student date of birth*

MonthDayYear
Date
Student gender*

MaleFemaleOther
Student ethnicity*

Hispanic or LatinoNon-Hispanic or non-LatinoUnknown
Student race*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteOtherUnknown
School this student attends for in-person learning*

Harrison High SchoolLouis M. Klein Middle SchoolHarrison Avenue Elementary SchoolParsons Memorial Elementary SchoolPurchase Elementary SchoolSamuel J. Preston Elementary School
Grade level of this student*
Please review the following information and provide your consent below.
1. I understand that New York State law allows some information about my child to be shared with and among certain County and New York State agencies (e.g., NYS Department of Health, Westchester County Health Department, Contracted Service Providers for COVID-19 Testing). This information will be shared only for public health purposes, which may include notifying close contacts of my child if they have been exposed to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your school community. Information about my child that may be shared includes my child’s name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name(s), teacher(s), enrollment and attendance, and after school or other program participation, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about my child will only be done in accordance with applicable law and the Harrison Central School District’s policies protecting student privacy and the security of my child’s data.
2. I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.
3. I consent for my child to be tested for COVID-19.
4. I understand that my child may be tested more than once through June 30, 2021, and I understand I will be notified each time before my child is tested.
5. I understand that this consent form will be valid through June 30, 2021, unless I notify the designated contact person from my child’s school in writing that I revoke my consent.
6. I understand that my child’s test results and other information may be disclosed as permitted by law.
7. I acknowledge that a positive test result will require my child to be sent home from school and remain at home until he/she meets the criteria to return to school according to state and local guidelines.
8. I understand that this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action regarding my child’s health and medical care as well as in response to any test results.
9. I understand that if I am a student age 18 or older, or 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.
Click YES below to provide consent:*

YES, I willingly and knowingly give consent to the provisions detailed above.
Employee Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Employee ethnicity*

Hispanic or LatinoNon-Hispanic or non-LatinoUnknown
Employee race*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteOtherUnknown
Work location*

Harrison High SchoolLouis M. Klein Middle SchoolHarrison Avenue Elementary SchoolParsons Memorial Elementary SchoolPurchase Elementary SchoolSamuel J. Preston Elementary SchoolDistrict Office
Select your role*
Please review the following information and provide your consent below.
1. I understand that New York State law allows some information about me to be shared with and among certain County and New York State agencies (e.g., NYS Department of Health, Westchester County Health Department, Contracted Service Providers for COVID-19 Testing). This information will be shared only for public health purposes, which may include notifying close contacts if they have been exposed to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your school community. Information about you that may be shared includes your name and COVID-19 test results, date of birth/age, gender, race/ethnicity, work location, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about you will only be done in accordance with applicable law and the Harrison Central School District’s policies protecting student privacy and the security of your personal data.
2. I have signed this form freely and voluntarily on my own behalf.
3. I consent to be tested for COVID-19.
4. I understand that I may be tested more than once through June 30, 2021, and I understand I will be notified each time in advance of testing.
5. I understand that this consent form will be valid through June 30, 2021, unless I notify the Office of Human Resources in writing that I revoke my consent.
6. I understand that my test results and other information may be disclosed as permitted by law.
7. I acknowledge that a positive test result will require me to be sent home from work and remain at home until I meet the criteria to return to work according to state and local guidelines.
8. I understand that this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action regarding my health and medical care as well as in response to any test results.
Click YES to provide consent:*

YES, I willingly and knowingly give consent to the provisions detailed above.
Should be Empty:

Harrison Central School District