Employee Forms

Lackawanna City School District

COVID 19 Testing Consent Form



Student First and Last Name: _______________________________


School: ________________________


Grade: ___________ Date of Birth:___________


Home Address: _______________________________


Parent Phone Number: _________________


Please indicate your child’s gender: ____________________________________


Choose the child’s Race/Ethnicity:

American Indian or Alaska Native            Asian           Hispanic or Latino

Black or African American            Native Hawaiian or Other Pacific Islander

White          Multi-racial

Overview of programs, for full testing program details please visit: www.lackawannaschools.org

Diagnostic Testing Program:
Consistent with ECDOH and NYSDOH return to school/work protocol, Lackawanna City School District (LCSD) requires a documented negative antigen or negative NAAT (PCR) test for COVID-19 for symptomatic students and staff to return to school/work (24 hours fever free and mild symptoms).

LCSD will provide "on site" COVID-19 diagnostic testing (performed by school nurses within the school health office) for consenting students and staff that develop symptoms during the school day.

Additionally, LCSD will provide "on site" COVID-19 diagnostic testing clinic for students and staff that develop symptoms outside of the school day. This is not a walk in clinic, you must have a referral from the building school nurse.

Test to Stay (TTS) Program:
The ECDOH has approved a Test to Stay (TTS) program for all schools within Erie County. LCSD will implement a Test to Stay (TTS) program to allow asymptomatic unvaccinated school-based close contacts (students and staff) to avoid school exclusion (but not other restrictions of quarantine) by testing negative through serial testing using rapid NAAT or antigen tests during a five-day period following exposure.




Students and staff who are asymptomatic and unvaccinated against COVID-19 and who are exposed to COVID-19 may attend in person classes, even while under mandatory quarantine orders if:

1. the person is symptom free
2. the school has received consent for the student to undergo daily COVID-19 testing, and
3. the person is tested a minimum of two times during a five-day period following exposure, unless recognition of the exposure is delayed or weekends or school breaks intervene. One of the tests must occur on day five.

LCSD COVID-19 testing programs begin on January 27, 2022. Please complete the form below to provide consent to participate in the LCSD COVID-19 Diagnostic Testing Program and/or TTS Program. Parents/guardians should complete one form per student



_____________________________            ______________________________

Parent Name (Print)                                     Parent Signature






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