1. Authorization and Consent for COVID-19 Diagnostic Testing:
• I voluntarily consent and authorize the USD 490 district to conduct the collection, testing, and analysis for the purposes of a COVID-19 diagnostic test.
• I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample through a nasopharyngeal swab collection procedure.
• I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false-positive or false-negative test results.
• I assume complete and full responsibility to take appropriate action concerning my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I understand that I am not creating a patient relationship with USD 490 by participating in this testing. I understand the testing unit is not acting as my medical provider.
2. Patient Rights and Privacy Practices
• I acknowledge and agree that USD 490 may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.
• I acknowledge and agree that some limited personal information including my name and contact information may be shared with public health authorities if I am identified as close to a positive case.
• To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, USD 490, including, without limitation, any its respective officers, directors, employees, representatives, and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of my COVID-19 testing and test results.
By providing my electronic signature to USD 490, I acknowledge and agree that I have read, understand, and agreed to the statements within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, and potential risks and benefits. I may decline to receive continued services. I understand that this consent form is valid for the 2021-2022 school year. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19.