Student Informed Consent Form

 
 
  

 
  NORTH SHORE SCHOOL DISTRICT 112 STUDENT INFORMED CONSENT SAFEGUARD SURVEILLANCE SCREENING PROGRAM
   
  North Shore School District 112 (“District”) seeks to maintain a safe environment for employees, students, and their families in light of the COVID-19 outbreak. This Informed Consent form provides your consent for your student to participate in a non-diagnostic “RT-LAMP” assay (“Assay”) and for the District to disclose the Assay results as permitted or required by law or guidance.
   
  Overview
   
  The Assay consists of a small non-invasive saliva collection, whereby saliva will be collected by the individual in a sterile test tube. The saliva will then be screened to indicate the potential presence of COVID-19. Saliva samples will be used for the sole, exclusive purpose of performing the Assay. Samples will be destroyed following the screening in a manner appropriate for biological specimens. Results obtained will be used for the sole purpose of surveillance in the District, as described herein.

In the event that your student’s Assay results indicate a potential presence of COVID-19, you will be notified of “findings of potential clinical significance” and be encouraged to contact your doctor for additional testing. This Assay alone is not sufficient to detect or rule out the possibility that your student has been exposed to or are infected with COVID-19. You should carefully monitor your student’s symptoms and, notwithstanding the results of any Assay, your student must stay home and consult with a physician if your student experiences symptoms of COVID-19.

The Assay is not a comprehensive or diagnostic COVID-19 test and is intended solely as an additional surveillance tool (similar to taking someone’s temperature). The Assay has not been reviewed or approved by the U.S. Food and Drug Administration or any applicable governmental agency or board.

You have the right to discuss the proposed Assay with your student’s physician, to learn about the purpose, potential risks and benefits of the Assay. Because of the ongoing public health crisis, the District will treat findings of potential clinical significance using this screening tool the same way that we will treat the outcomes of surveillance and safety measures we are employing, such as temperature measurements or observable COVID-19 like symptoms. Individuals receiving notification of findings of potential clinical significance would be required to stay home and self-isolate until cleared pursuant to current public health guidance and District procedures.
   
  Disclosure of Protected Health Information
   
  Assay results will be shared with the student’s parent/guardian for the purpose of seeking additional medical treatment and will be available to any employees of the District with a legitimate educational interest, consistent with the Illinois School Student Records Act. The District will only disclose your student’s Assay results as permitted or required by law or guidance.
   
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  This consent and authorization is effective upon signature and will be valid through June 30, 2021, unless revoked in a written notice to the District.
   
 
 
 
 Done