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Consent for SHIELD Testing

By signing below, this informed consent provides Joliet Township High School District 204 (JTHS D204) authorization to administer a “SHIELD Illinois Rapid rtPCR” test (“Test”) to your child once per week unless otherwise communicated by the district as one part of our COVID-19 Safety Protocols that also include social distancing, mandated mask-wearing and regular cleaning. The Test will be supervised by an individual appropriately trained in monitoring the administration of the test and conducted through saliva collected in a test tube by the individual being tested for screening purposes only. The purpose of providing the Test is based on the District’s desire to maintain a safe environment to the greatest extent possible for its employees and students, and other essential persons with whom your child may come into contact while at school. 

By signing this form I acknowledge that I am fully aware that the Test being provided by JTHS D204 may involve COVID-19 tests that have not undergone a full FDA approval process and instead have obtained emergency use authorization (EUA) or are registered and pending such processing and that the results could produce false positives or false negatives, or be administered in a way that otherwise produces inaccurate results. I am also fully aware that this is a non-diagnostic Test and that JTHS D204 is not providing medical care or giving a medical diagnosis with the administration of the Test. I further understand and agree by my signature below that I should consult my doctor or go to an emergency room if my child or I have any questions, serious symptoms, and/or to obtain medical advice from my own doctor as to the results of the Test.

Test results will be reported by JTHS 204 to the parent or guardian of each child via email within 24 hours of the District’s receipt of test results. A member of the District 204 Student Health team will be in immediate phone contact with the parent or guardian of any student who tests positive for COVID-19 and will provide next steps in accordance with IDPH/Will County Health Department Exclusion Procedures and Protocols.
By signing below:

(1)    I hereby waive my student’s rights regarding protected health information under HIPAA, as applicable, FERPA, and/or ISSRA, to the extent necessary to complete the testing and to allow JTHS D204 and/or SHIELD Illinois to provide my child’s results (whether positive or negative) of the Test to local and state public health authorities (which may result in further direct communication from those entities to me for follow-up and/or contact tracing). Any disclosure of my child’s protected health information will only be for purposes of public health and safety and protected health information will not be reused or disclosed by JTHS D204 to any person or entity other than above, except as required by law.

(2)    I voluntarily acknowledge that I have the right to consult with my Doctor and/or my child’s physician prior to testing of my child;

(3)    I voluntarily acknowledge that I have been provided an opportunity to ask questions before proceeding with the COVID-19 Test;

(4)    I acknowledge and agree that if I do not wish to continue to have my child be administered the Test that I may decline and/or revoke this consent and my child will not be tested. However, I also understand and agree that if I do not consent to the administration of the Test for my child that the result will be one or more of the following: (a) I and my child will be required to abide by the IDPH/Will County Health Department Exclusion Procedures and Protocols; (b) I will have to submit an exemption request, in writing, to my child's principal and the District Contact Tracer for my child; and (c) I and my child will be required to abide by all District based mitigation efforts.

(5)    I voluntarily consent to this Test for the purpose of determining whether my child has COVID-19 for non-diagnostic purposes;

(6)    I voluntarily consent to the disclosure of Test results to the District Testing Medical Professional which will be maintained as a medical record in the same manner that the District currently maintains other medical records such as immunizations and physicals;

(7)    I voluntarily agree to cooperate with the District in any contract tracing procedures and/or protocols as detailed in the District 204 On-Site Testing Plan, if applicable;

(8)    I voluntarily acknowledge that I have read and agree with the Privacy and Other Considerations in the District 204 On-Site Testing Plan;

(9)    I voluntarily agree to hereby release, discharge, and hold harmless, the Board, its members, employees, agents, officials, officers, insurers and/or attorneys, 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 child’s COVID-19 Test or the disclosure of my child’s COVID-19 Test Results in accordance with the District 204 On-Site Testing Plan;

(10)    I attest that I am legally authorized to make decisions for the child named within this consent form; and

(11)    I understand that this informed consent form will be valid through the 2021-2022 school year, unless I revoke my consent in a written letter to my child’s principal sooner. I understand that if I revoke my consent or refuse to sign this consent form and my child is not fully vaccinated, my child will be required to follow the mitigation procedures for vaccinated students.

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I authorize JTHS District 204 to administer a “SHIELD Illinois Rapid rtPCR” test to my child in accordance with the terms listed above.​
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