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.
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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
______________
Date