PS 55 The Henry M. Boehm School

What is this form?

We are seeking your consent to test your child for COVID-19 infection. The New York City Department of Education (NYC DOE), working with NYC Health + Hospitals and the New York City Department of Health and Mental Hygiene, has partnered with laboratories and other providers to test NYC DOE students, teachers, and staff members for COVID-19 infection.

How often would you test my child?

We are arranging for our laboratory and provider testing partners to come to every school at least once a month to test some of the students and staff. If you consent, your child may be selected for testing on one or more of these occasions. In addition, your child may also be tested throughout the school year (1) in accordance with state and city mandates, such as weekly testing in schools in Yellow Zones, or (2) if they exhibit one or more symptoms of COVID-19, or (3) if they are a close contact of a student, teacher, or staff person with COVID-19 infection.

What is the test?

If you consent, your child will receive a free diagnostic test for the COVID-19 virus. The attached letter provides more information about the types of tests that may be used. Collecting a specimen for testing involves inserting a small swab, similar to a Q-Tip, into the front of the nose and/or collecting saliva (spit).

How will I know if my child tests positive?

If your child has a specimen collected for testing at school, we will send information home with them to let you know. COVID- 19 test results will generally be provided within 48-72 hours.

What should I do when I receive my child’s test results?

If your child’s test results are positive, please contact your child’s doctor immediately to review the test results and discuss what you should do next. You should keep your child at home and inform your child’s school. If your child’s test results are negative, this means that the virus was not detected in your child’s specimen. Tests sometimes produce incorrect negative results (called “false negatives”) in people who have COVID-19. If your child tests negative but has symptoms of COVID-19, or if you have concerns about your child’s exposure to COVID-19, you should call your child’s doctor. If you need help finding a doctor, call (844) NYC-4NYC.

TO BE COMPLETED BY PARENT, GUARDIAN OR ADULT STUDENT

Parent/Guardian Information

Parent/Guardian Print Name:

Parent/Guardian

Address:

Parent/Guardian Tel./Mobile #:

Parent/Guardian

Email address:

Best way to contact you

Child/Student Information

Child/Student Print Name:

Child/Student School ID/OSIS #:

Child/Student Date of Birth:

Child/Student

School

Child/Student

Address:

NOTIFICATION OF INFORMATION SHARING

The law allows some information about your child to be shared with and among certain New York City and New York State agencies and their contracted service providers, including those listed below. This information will be shared only for public health purposes, which may include notifying close contacts of your child if they have been exposed to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your school community. Information about your child that may be shared with these agencies and service providers conducting COVID-19 Testing includes your child’s name and COVID-19 test results, date of birth/age, gender, race/ethnicity, school name(s), teacher(s), classroom/cohort/pod, enrollment and attendance history, and afterschool or other program participation, names of other family members or guardians, address, telephone, mobile number, and email address. Sharing of information about your child will only be done so in accordance with

applicable law and City policies protecting student privacy and the security of your child’s data.

·       NYC Department of Education

·       NYC Department of Youth and Community Development

·       NYC Department of Health and Mental Hygiene

·       NYC Health and Hospitals Corporation

·       NYS Department of Health

·       Contracted Service Providers for COVID-19 Testing

CONSENT

By signing below, I attest that:

·       I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named above.

·       I consent for my child to be tested for COVID-19 infection.

·       I understand that my child may be tested at multiple times through September 30, 2021, and that testing may occur (1) on days scheduled by the NYC DOE in accordance with state and city mandates, such as weekly testing in schools in Yellow Zones, or (2) if they exhibit one or more symptoms of COVID-19, or (3) if they are a close contact of a student, teacher, or staff person with COVID-19 infection.

·       I understand that this consent form will be valid through September 30, 2021, unless I notify the designated contact person from my child’s school in writing that I revoke my consent.

·       I understand that if I revoke my consent or refuse to sign, my child may be required to continue their education via remote learning.

·       I understand that my child’s test results and other information may be disclosed as permitted by law.

·       I understand that if I am a student age 18 or older, or may otherwise legally consent for my own health care, references to

“my child” refer to me and I may sign this form on my own behalf.

Signature of Parent/ Guardian* (if child is under age 18)

Date

Signature of Student

(if age 18 or over or otherwise authorized to consent)

Date