Universal COVID-19 Consent Testing Form (Highline Public Schools)

Highline Public Schools COVID-19 Testing Consent Form

This form is for all students, staff and household members that receive a COVID-19 test through Highline Public Schools. More information on the Highline Public Schools Testing Program can be found on our website (https://www.highlineschools.org).
Highline Public Schools has collaborated with the Washington State Department of Health to be able to offer free COVID-19 testing to students, staff, and families. The COVID-19 tests are shallow nasal swabs, which are quick and painless, and will be self-administered under observation by a trained person. We require your informed consent for the above-named individual to be able to participate in diagnostic, screening, and follow-up (reflex) COVID testing.
Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Age *
Gender *

Female Male Other
Is this testing consent for a student, staff, or household member of Highline School District? *

Student Staff Household Member
Parent/Guardian Name (if under 18 years old) *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email Address *
example@example.com
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
School *
For household members: Please select a site that you are associated with.
Site or School *
If you primarily work at a school site, please select that site.
Grade *

SCREENING TESTING PERMISSIONS (AtlasGenomics) – FOR HIGHLINE STUDENTSAND STAFF ONLY
- I authorize the above-named individual to participate in the pooled COVID-19 testing program to include collection of specimens during school hours by school personnel and subsequent analysis by Atlas Genomics.
- I understand that I will not receive an individual result for the above-named individual from the pooled testing and that such individual results from pooled testing cannot be provided to me. The above-named individual’s personal health information and personally identiﬁable information from education records will not be provided to Atlas Genomics in connection with it performing COVID-19 pooled testing.
- I understand that in the event of a positive test result within the above-named individual’s screening testing cohort, follow-up or reflex testing will be necessary to determine the positive case(s) within the cohort.

DIAGNOSTIC TESTING PERMISSIONS (Curative, Atlas Genomics, and rapid antigen tests by Highline Staff)
- I understand that in the event of a positive test result within the above-named individual’s screening testing cohort, follow-up or reflex testing will be necessary to determine the positive case(s) within the cohort via the rapid antigen tests, Curative PCR testing, or Atlas Genomics PCR testing. Testing will be self-administered and observed by trained school personnel.
- I understand and acknowledge that a positive diagnostic test result is an indication that the above-named individual needs to self-isolate to avoid infecting others.
- By indicating my consent below, I authorize Atlas Genomics and/or Curative to release the results of the above-named individual’s COVID-19 test results to Highline Public Schools. This information will be used to make sure our students and staff can be safely at school during the COVID-19 pandemic.
- I authorize Atlas Genomics, LLC, Curative Inc., and Curative Labs, LLC, as applicable, to disclose the above-named individual protected health information to Highline Public Schools
- I affirm that Highline Public Schools has the legal authority to determine who may receive the protected health and education information pertaining to the above-named individual.
- I have the right to revoke this authorization at any time by doing so in writing to support@curativeinc.com.
- Any revocation of this authorization by me will not apply to actions that any of Atlas Genomics, LLC, Curative Inc., Curative Labs, LLC, and/or Dr. Sajad Zalzala M.D. have already taken regarding the sharing of protected health information during the period that my authorization was valid.

COVID-19 TESTING PERMISSIONS - ALL
- I understand that false positive or false negative COVID-19 test results may occur in pooled or individual tests. Due to the potential for a false negative result, I understand that the above-named individual 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 the above-named individual develops symptoms of COVID-19.
- I understand that the personnel administering pooled and follow-up testing have received appropriate training on how to properly administer the test using all applicable safety guidelines. I agree that neither the test administrator nor Highline Public Schools, nor any of its trustees, ofﬁcers, employees, or organization sponsors are liable for any accident or injuries that may occur from the above-named individual’s participation in the testing program.
- I understand that the antigen test result will be available in 10-30 minutes.
- I understand that the above-named individual must stay home if feeling unwell. I acknowledge that a positive individual follow-up test result requires that the above-named individual stay home from school, self-isolate, and continue wearing a mask or face covering as directed by school or public health ofﬁcials.
- I understand the school system is not acting as the above-named individual’s medical provider or providing any medical advice and that this testing does not replace treatment by the above-named individual’s medical provider. I assume complete and full responsibility to take appropriate action with regards to the above-named individual’s test results and I agree I will seek medical advice, care, and treatment from the above-named individual’s medical provider if I have questions or concerns or if their condition worsens. I understand I am ﬁnancially responsible for any care the above-named individual receives from their healthcare provider.
- I understand it is my responsibility to inform the above-named individual’s health care provider of a positive test result, and that a copy will not be sent to the above-named individual’s health care provider for me.
- I understand that the test results will be disclosed to the appropriate public health authorities, the Office of Superintendent of Public Instruction, and as otherwise permitted or required by law.
- I understand that authorizing COVID-19 testing for the above-named individual is optional and that I may refuse to give this authorization, in which case, the above-named individual will not be tested.
- I understand that I may cancel this authorization at any time, but that such cancellation applies to future testing only, and will not affect information I already authorized to be released. To cancel this authorization for COVID-19 testing, I must contact the above-named individual’s school or department.

Signature
By signing below, I, the undersigned, voluntarily consent to diagnostic AND screening testing (as applicable) for the above-named individual unless otherwise indicated below.

I have been informed about the test purpose, procedures, potential risks, and I have been offered a copy of this Informed Consent. I have been provided the opportunity to ask questions before I sign, and I have been told that I may ask additional questions at any time. I voluntarily agree to authorize the above-name individual to be tested if they have symptoms or had exposure to a positive individual via Atlas Genomics PCR, Curative PCR, and/or rapid antigen COVID-19 tests. I further authorize the School District to share the above-named individual’s protected health information with Atlas Genomics and Curative, as applicable, for identification purposes. Finally, I understand that, per the Washington State Department of Health, an individual with COVID-19 or COVID-19 symptoms cannot attend school in person.
Signature of Parent/Guardian OR Individual (age 18 or older) *

Clear
Name *

First Name Last Name
Date Received by School District *

Month Day Year
Date

OPTIONAL OPT-OUT PERMISSIONS
OPTIONAL OPT-OUT:

I DO NOT consent to screening testing for the above-named individual for the 2021-2022 school year. (For students and staff only) I DO NOT consent to diagnostic testing for the above-named individual for the 2021-2022 school year.

FOR OFFICE USE ONLY

Review and Submit Consent
Should be Empty:

Highline Public Schools COVID-19 Testing Consent Form