Student/Staff Consent Form for Covid-19 Testing

 
Page 1 of 1
 
  

 
  STUDENT/STAFF CONSENT FORM FOR OPTIONAL COVID-19 TESTING

The Round Top-Carmine ISD takes the health and safety of our students and their families very seriously. As such, in addition to steps to screen for the virus and prevent its spread on a campus, we are adding a voluntary K-12 COVID-19 testing program for students and staff who have symptoms of COVID-19 illness or have had close contact with a positive COVID-19 individual. This program uses Abbott Laboratories BinaxNOW tests provided by the federal government. We will only test with consent. If you are willing to provide consent for us to administer this test on your child or yourself (staff member or student age 18 or older), please fill out this form.

What is the test?
RT-C ISD will use the free BinaxNOW rapid test for the COVID-19 virus provided to schools by the federal government. Collecting a specimen for testing involves using a swab, similar to a Q-Tip, placed inside the tip of the nose. A school staff member who has been trained to use this test will collect or supervise self-collection of the specimen and a trained COVID-19 test administrator will oversee the process. Test results will be made available to the individual who signs this form below. The results will be read at 15 minutes and available immediately. This program is entirely optional , although we hope you choose to have the test to keep our schools as healthy & safe as possible. The tests are being offered in addition to existing safety protocols such as mask-wearing, social distancing, and frequent disinfection of surfaces.
What should I do when I receive the test results?
If the test is positive for the virus, the students will be moved to a room away from other students and staff until you can pick him/her up. Staff will immediately be sent home to quarantine. We ask that individuals testing positive stay home until the infection period has ended (typically, after symptoms improve and at least 10 days from the date symptoms first appear) and until no longer contagious. If the test results are negative, the virus was not found in the specimen tested and the individual may continue to attend school without interruption. In a small number of cases, tests sometimes produce incorrect results – showing negative results (called “false negatives”) in people who have COVID-19 or showing positive results (called “false positives”) in people who don’t have COVID-19. If a staff member or student tests negative but has symptoms of COVID-19, or if you have concerns about exposure to COVID-19, you should call a physician, a licensed medical authority, or your local health department.

Known Symptoms:
People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

• Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit
• Loss of taste or smell
• Cough
• Difficulty breathing
• Shortness of breath
• Fatigue
• Headache
• Chills
• Sore throat
• Congestion or runny nose
• Shaking or exaggerated shivering
• Significant muscle pain or ache
• Diarrhea
• Nausea or vomiting

This list does not include all possible symptoms.

Disclaimer:
While we realize precautions will be taken for the safety of students, please understand that neither the test admnistrator nor the Round Top-Carmine ISD nor any of its trustees, officers, employees, or organization sponsors are liable for any accident or injuries that may occur to your child or yourself (if staff memeber or student age 18 or older), as a result of agreeing to the test.

   
  TO BE COMPLETED BY PARENT, GUARDIAN OR ADULT STUDENT/STAFF MEMBER
   
1.
*
 
   
2.
*
 
   
3.
 
   
  CHILD/STUDENT/STAFF MEMBER INFORMATION
   
4.
*
 
   
5.
 
   
6.
 
   
7.
*
Enter at least 4 responses.
 

 

 

 

 
   
8.
*
Select at least 1.
 
  
  
   
9.
*
 
   
10.
*
 
   
11.
 
   
12.
*
Select at least 1.
 
  
  
  
  
  
  

    
   
13.
*
Select at least 1.
 
  
  
  
   
  CONSENT
   
  By signing below, I attest that:

A. I authorize the Round Top-Carmine school system to conduct collection and testing of my child or me (if studentor staff age 18 or older) for COVID-19 by nasal swab.
B. I acknowledge that a positive test result is an indication that my child or me (if staff or student age 18 or older), must self-isolate and also continue wearing a mask or face covering as directed in an effort to avoid infecting others.
C. I understand the school system is not acting as my or my child’s medical provider, this testing does not replace treatment by my child‘s medical provider, and I assume complete and full responsibility to take appropriate action with regards to the test results. I agree I will seek medical advice, care and treatment from my or my child’s medical provider if I have questions or concerns, or if their condition worsens.
D. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

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.

   
14.
Your typed name is considered your electronic signature.
 
   
15.
  Select Date
mm/dd/yyyy
   
16.
Your typed name is considered your electronic signature
 
   
17.
  Select Date
mm/dd/yyyy
   
 
 
 
 Done  Save  Cancel