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(“Testing Partner”) Your School District has opted to participate in the Program, which is a FREE COVID-19 PCR saliva testing for our schools’ teachers, students, and staff. The NJDOH is sponsoring the Program, along with its lab testing partner: Mirimus Inc. The State of New Jersey, acting through the New Jersey Department of Health (”NJDOH”), is sponsoring the New Jersey Schools COVID-19 Screening Testing Program (the “Program”) for all schools and school districts in New Jersey. Signature or Parent/Guardian signature if Student is under the age of 18.
By signing this form, I acknowledge that I have read and accept all of the above.
I have read this form and all of my questions have been answered to my satisfaction. I will receive positive test results and will take appropriate actions. I understand and acknowledge that NJDOH, its contractors, and the school/district are not acting as the medical provider and this Program is not for testing if a person is sick or exposed to a person with COVID-19. Has passed since the positive test result. I understand that if my child/legal guardian/I have tested positive for COVID-19 within the last 90 days, my child/legal guardian/I will not be able to participate in the Program until 90 days I understand that I have the right to revoke this consent at any time by notifying in writing the school nurse or whomever the school designates in writing to receive such notice. I authorize the release of information as indicated in the Frequently Asked Questions as part of the Program for public health purposes.īy signing this, I am giving permission for my child/legal guardian or myself to participate in this voluntary testing Program. I understand there will be no cost to me for this testing Program. I have read and understand the attached Frequently Asked Questions about the New Jersey Schools COVID-19 SCREENING TESTING PROGRAM (the “Program”). I authorize the New Jersey Department of Health, (the “NJDOH”) and it contractors to receive self-collected saliva samples on the above named individual and conduct COVID-19 screening tests on those samples.
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