Unit 40 Symptomatic & Test-to-Stay COVID-19 Testing

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Name of Student or Employee* This field is required.You should complete one form per student or employee.
First Name
Last Name
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Date of Birth for Student or Employee Seeking Testing* This field is required.Please use format xx/xx/xxxx.
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Date of Birth for Student or Employee Seeking Testing* This field is required.
Date
Month
Day
Year
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Name of Parent/Guardian* This field is required.This form should only be completed by the parent or legal guardian for students less than 18 years of age seeking COVID-19 testing at Effingham Community Unit School District #40. If you are an employee or over the age of 18, you may enter your own name in this section.
First Name
Last Name
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Email of Parent/Employee* This field is required.If you are filling out this form for your child, please provide your parent/guardian email address. If you are filling out this form as an employee, please provide your preferred email.
example@example.com
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Contact Cell Number for Results* This field is required.This must be a mobile number and, if positive, will be the number provided to IDPH. If you are filling out this form for your child, please provide your parent/guardian cell phone number.
Please enter a valid phone number.
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School/Facility* This field is required.Please select the school the student or employee attends.
East Side Preschool
Early Learning Center
South Side
Central Grade School
Effingham Junior High School
Effingham High School
Board Office
Transportation
Maintenance
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A COVID-19 test is sought because the employee or student is....* This field is required.
Symptomatic
A Close Contact (Test-to-Stay)
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If symptomatic, when did symptoms start? OR If testing to stay, when was the last day of close contact with the positive case?* This field is required.
Date
Month
Day
Year
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Check all boxes that apply.* This field is required.Reminder: This test is only available to Unit #40 students and employees that are symptomatic or have been determined a close contact and are testing to stay.
The employee or student is NOT experiencing symptoms but has been determined a close contact (test-to-stay).
Fever
Cough
Chills
Shortness of breath/difficulty breathing
Fatigue
Muscle or body Aches
Headache
New loss of smell or taste
Congestion or runny nose
Sore throat
Nausea or vomiting
Diarrhea
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Authorization and Consent

Effingham Community Unit School District #40:

Symptomatic & Test-to-Stay BinaxNOW
Testing Program Authorization and Consent for COVID-19 Testing of Minor

To be completed by parent or legal guardian of student less than 18 years of age seeking COVID-19 testing through the Unit #40 Symptomatic & Test-to-Stay BinaxNOW testing program.

Effingham Community Unit School District #40 has implemented a rapid testing program in the K-12 setting. As the parent/legal guardian of a minor student (“Student”), I hereby authorize and give my express consent to Effingham Community Unit School District #40 for my Student to be tested for COVID-19 under the authorization of a supervising physician and the IL Dept. of Health. I understand that a sample will be collected from my Student and tested for COVID-19 using the BinaxNOW COVID-19 Antigen Test (nasal swab).

If the student receives a positive result, you will be contacted immediately and the Student must leave school. Your Student will be required to follow the normal process of obtaining documentation from the Illinois Department of Public Health's Surge Center prior to returning to school. The potential benefits of testing include helping you, the student, and student’s healthcare provider make informed decisions about Student’s care, and helping to limit the spread of COVID-19.

I understand the potential risks include the possibility of incorrect test results because of related false positives and false negatives. I understand that Effingham Community Unit School District #40 is not acting as Student’s medical provider and that this testing does not replace treatment by Student’s medical provider. I assume complete and full responsibility to take appropriate action with regard to my student’s test results. I agree I will seek medical advice, care, and treatment from student’s medical provider if I have questions or concerns, or if my student’s condition worsens.

Disclosure to Government authorities: I acknowledge that Student’s COVID-19 test results and associated information may be shared with appropriate county, state, or other governmental and regulatory entities as may be permitted by law. I permit Effingham Community Unit School District #40 to release Student’s test results and associated information with the persons or entities required to control, prevent, or mitigate the spread of COVID-19.

Release: To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, the Effingham Community Unit School District #40, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my Student’s COVID-19 diagnostic test or the disclosure of my Student’s COVID-19 test results.

Symptomatic & Test-to-Stay BinaxNOW
Testing Program Authorization and Consent for COVID-19 Testing of Employee

To be completed by employee to utilize the Unit 40 symptomatic & test-to-stay BinaxNOW testing program.

As an employee of the District, I hereby authorize and give my express consent to be tested for COVID-19 under the authorization of a supervising physician. I understand that a nasal swab sample will be collected and tested for COVID-19 using the BinaxNOW COVID-19 Antigen Test.

If you receive a positive result, District staff will contact you and you should immediately leave the premises. You will be required to follow the normal process of obtaining documentation from the Illinois Department of Public Health's Surge Center before returning to school/work. The potential benefits of testing include helping you and your healthcare provider make informed decisions about you care and helping to limit the spread of COVID-19. I understand the potential risks include the possibility of incorrect test results because of related false positives and false negatives. I understand that Effingham Community Unit School District #40 is not acting as my medical provider and that this testing does not replace treatment by my medial provider. I assume complete and full responsibility to take appropriate action with regard to my test results. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

Disclosure to Government authorities: I acknowledge that my COVID-19 test results and associated information may be shared with appropriate county, state, or other governmental and regulatory entities as may be permitted by law. I permit Effingham Community Unit School District #40 to release my test results and associated information with the persons or entities required to control, prevent, or mitigate the spread of COVID-19.

Release: To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, the Effingham Community Unit School District #40, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.

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Parent/Guardian or Employee Authorization & Consent Signature* This field is required.Parents/Guardians: I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test and potential risks and benefits. This authorization is valid until revoked in writing by the parent or legal guardian or is no longer necessary under the law. I have the legal authority, based upon my relationship to Student, to consent to this test administration for the Student. Employees: I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test and potential risks and benefits. This authorization is valid until revoked in writing or is no longer necessary under the law. Parent/Guardian of student minor or Employee must sign in the box below for authorization and consent for the BinaxNOW test.
Clear
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PLEASE REMEMBER YOUR CHOICE* This field is required.Options for report time are listed below. Only 6 patients allowed per time slot.
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BinaxNOW Test Site Location- EHS Parent Drop-OffTesting will be conducted at the EHS parent drop-off (southwest shop entrance). Please enter from Rt. 40 entrance. Park in the marked parking spots (#1 through #6) at your scheduled appointment time and someone will be out to test you in your vehicle. Address for Effingham High School: 1301 Grove Ave, Effingham, IL 62401 Don't forget to hit SUBMIT.
Should be Empty:

Authorization and Consent

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