Voluntary COVID-19 Testing Consent & Acknowledgement Form for the Lebanon School District Testing Information:

BinaxNOW is an antigen test that detects the presence of the SARS-CoV-2, which is the virus that causes a COVID-19 infection, in about fifteen (15) minutes. The specimen for the test is collected via a nasal swab. This test is completely voluntary and will not ever be administered unless this form is signed. Submitting this form does not require or guarantee that you will receive an inaxNOW test. At this time, test supply is limited and the test is currently only able to be administered to individuals suffering from symptoms consistent with an infection of COVID-19. A negative test result, however, may indicate that those symptoms are actually the result of a common cold, allergies, or a different illness. In addition, while the test has been shown to provide a high level of accuracy, it is not 100% accurate. If symptoms consistent with an infection of COVID-19 develop or persist after a negative test result, you must consult with a health care provider to determine the best course of action. For more information about the test, see “Missouri’s BinaxNOW Antigen Testing Program for K-12
Institutions,” available here:
https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/pdf/binaxnow-guidanceeducation.pdf .

Result Reporting:
A positive result of the BinaxNOW test will be immediately reported to the Laclede County Health Department or County Health Department of residence so that it can begin contact tracing and instituting any disease control measures it deems appropriate. The Laclede County Health Department solely manages these efforts in Laclede County. Additionally, all test results will be shared with the Department of Health and Senior Services pursuant to state regulation. Except as required or allowed by law, test results and testing information will be kept confidential by the Lebanon School District, Laclede County Health Department, and Department of Health and Senior Services. For more information, please see “School Reporting of a Positive or Suspected OVID-19 Student or Employee,” enclosed and accessible here: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/pdf/school-covid-reporting.pdf  A positive result of the BinaxNOW test may also result in the tested student’s, employee’s, or other individual’s removal from the testing premises.

Completing and signing this form serves as consent for the test to be performed on the named individual and is also an acknowledgment of the above statements as well as the content of the enclosed notice entitled “School Reporting of a Positive or Suspected COVID-19 Student or Employee.” Please note that all minor children’s parent or guardian will be called before a test is administered. Signed consent forms should be returned to your building nurse or main office.


Voluntary COVID-19 Testing Consent & Acknowledgement Form for the Lebanon School District

Print name of person to be tested: __________________________________________________

Status of person to be tested (circle): student employee other___________ (explain)

Print parent / guardian name (if applicable): __________________________________________

Date: ______________________

Signature of person tested or parent / guardian: ______________________________________

Received by (name) ______________________________ on (date) _________________

Place of test administration: _____________________________ on (date) ________________