Bellevue School District      Bellevue School District

 Covid Testing Consent 

Use the same username and password you use to login to your district account

Staff Name

Bellevue School District has collaborated with the Washington State Department of Health to be able to offer free COVID-19 testing to students and staff.The COVID-19 tests are shallow nasal swabs, which are quick and painless, and will be self-administered under observation by a trained person. We require your informed consent for the above-mentioned staff to be able to participate in diagnostic, screening, and follow-up (reflex) COVID testing.
Click to read more about Covid Testing at BSD

● I authorize my participation in the pooled COVID-19 testing program to include weekly collection of specimens during school hours by staff personnel and subsequent analysis by Atlas Genomics.
● I understand that I will not receive an individual result from the pooled testing and that such individual results from pooled testing cannot be provided to me. Neither my personal health information, nor personally identifiable information from staff records will be provided to Atlas Genomics in connection with it performing COVID-19 pooled testing.
● I understand that in the event of a positive test result within my screening testing cohort, follow-up or reflex testing will be necessary to determine the positive case(s) within the pool.

● I understand that BSD is providing individualized diagnostic testing, in the event of symptoms or exposure to a positive individual. BSD is also offering that, in the event of positive test result within my pooled screening testing cohort, follow-up or reflex testing can determine the positive case(s) within the cohort via Genomics PCR testing.
● Testing will be self-administered, and observed by trained staff personnel.
● I understand and acknowledge that a positive diagnostic test result is an indication that the above-named needs to self-isolate to avoid infecting others.
● I have the right to revoke/re-invoke this authorization at any time by returning to and selecting a Testing Consent option.
● Any revocation of this authorization by me will not apply to actions that Atlas Genomics, has already taken regarding the sharing of protected health information during the period that my authorization was valid.

● I understand that false positive or false negative COVID-19 test results may occur in pooled or individual tests. Due to the potential for a false negative result, I understand that my I should continue to follow all COVID-19 safety guidance, including mask-wearing and social distancing, and follow district protocols for isolating and testing in the event I develops symptoms of COVID-19.
● I understand that the personnel administering pooled and follow-up testing have received appropriate training on how to properly administer the test using all applicable safety guidelines. I agree that neither the test administrator nor Bellevue School District, nor any of its trustees, officers, employees, or organization sponsors are liable for any accident or injuries that may occur from my participation in the testing program.
● I understand that I must stay home if feeling unwell. I acknowledge that a positive individual follow-up test result requires that I stay home from district buildings, self-isolate, and continue wearing a mask or face covering as directed by district or public health officials.
● I understand the district is not acting as my medical provider or providing any medical advice and that this testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results and I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns or if their condition worsens. I understand I am financially responsible for any care I receive from my healthcare provider.
● I understand it is my responsibility to inform the above-named health care provider of a positive test result, and that a copy will not be sent to the above-named health care provider for me.
● I understand that authorizing COVID-19 testing is optional and that I may refuse to give this authorization, in which case, I will not be tested.
● I understand that I may cancel this authorization at any time, but that such cancellation applies to future testing only, and will not affect information I already authorized to be released.

● By indicating my consent below, I authorize Atlas Genomics to release the results of my COVID-19 test to Bellevue School District. I authorize Atlas Genomics, to disclose my protected health information to Bellevue School District.
● I understand that Bellevue School District has the legal authority to determine which District personnel may receive the protected health and education information pertaining to me, and that it will be on a “need to know” basis.
● I understand that any positive test results will be disclosed to the Seattle King County Department of Health and the Office of Superintendent of Public Instruction, and as otherwise required by law.

Sign Below using mouse, finger or stylus
Sign Above using mouse, finger or stylus
Print Your Name: