2021-22 COVID-19 Testing Consent Form (Students)

Harrison Central School District

2021-22 COVID-19 Testing Consent Form
The Harrison Central School District is partnering with Westchester County and Mount Sinai Health Systems to provide non-invasive PCR saliva tests for vaccinated and unvaccinated students. Conducting COVID-19 testing on a representative sample of vaccinated and unvaccinated students each week will help to limit the spread of COVID-19 and keep school open for in-person learning. This non-invasive PCR saliva test can be completed at home and will produce lab-confirmed results within 24 hours. We need parent consent for your child(ren) to participate in COVID-19 testing.

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 unvaccinated child that will participate in COVID-19 testing). Your consent is valid for the 2021-22 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 Westchester County 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.
Student Name*

First NameLast Name
Student ID Number*
Enter the student ID provided in the text message or email you received
Date of Birth*
Student Gender*

MaleFemaleOther
Student Race*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteOtherUnknown
Student Ethnicity*

Hispanic or LatinoNon-Hispanic or non-LatinoUnknown
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*
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.
Please review the following information and provide your consent below.
1. I authorize the Westchester County Department of Health, (the “WCDH”) and its contractors to receive self-collected saliva samples on the above named individual and conduct COVID-19 screening tests on those samples.
2. I have read and understand the Frequently Asked Questions about the Westchester County Schools COVID-19 SCREENING TESTING PROGRAM (the “Program”). I understand there will be no cost to me for this testing Program. I authorize the release of information as indicated in the Frequently Asked Questions as part of the Program for public health purposes.
3. By signing this, I am giving permission for my child to participate in this voluntary testing Program.
4. I understand that I have the right to revoke this consent at any time by notifying in writing the school nurse or whomever the school designates in writing to receive such notice.
5. I understand that if my child has tested positive for COVID-19 within the last 90 days, my child will not be able to participate in the Program until 90 days has passed since the positive test result.
6. I understand and acknowledge that WCDH, its contractors, and the school/district are not acting as the medical provider and this Program is not for testing if a person is sick or exposed to a person with COVID-19. I will receive positive test results and will take appropriate actions.
7. I authorize Westchester County Department of Health and its testing partners (Mount Sinai Health Systems, Inc., Mirimus Inc. and Quadrant Biosciences, Inc.) to disclose the above named individual’s COVID-19 PR saliva test results ("COVID Information") to the Harrison Central School District, 50 Union Ave, Harrison NY 10528 ("Recipient"). The purpose of disclosure is Participation in Westchester County Schools COVID-19 Screening Testing Program and School Attendance.
8. This authorization will expire one year from the date on which it was signed.
  This authorization permits the release of COVID information of the above-named individual to the above-named Recipient on an ongoing basis for however many COVID tests such individual undergoes before the expiration of this authorization.
9. I understand that any disclosure/release is bound by the Health Insurance Portability and Accountability Act of 1997 (HIPAA) 45 C.F.R. pts 160 & 164; and re-disclosure of this information to a party other than one designated above is forbidden without written authorization on my part, unless required or permitted under law or regulation.
10. I understand that the WCDH and its Testing Partners have no ability to prevent re-disclosure of my COVID information by Recipient.
11. Signing this authorization is voluntary. I understand that I have the right to revoke this authorization at any time, except to the extent that WCDH and its Testing Partners have already acted in reliance on it. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school nurse or whomever the school designates in writing to receive such notice.
12. I have read this form and all of my questions have been answered to my satisfaction. By signing this form, I acknowledge that I have read and accept all of the above.
Click YES to provide consent:*

YES, I willingly and knowingly give consent to the provisions detailed above.
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Harrison Central School District