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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