By signing below, I attest that:

• I am the parent/legal guardian of the child/student named above.  

• I am legally authorized to make healthcare-related decisions for the child/student named above. 

• I have signed this form freely and voluntarily. 

 • I consent for my child/student to be tested for COVID-19 infection through the school-based routine COVID-19 screening (testing) program being implemented at my child’s/student’s school. 

• I understand that there is no cost to me or to my family for these screening tests. 

• I understand that the testing program will follow the Centers for Disease Control and Prevention (CDC) Guidelines related to test type and frequency. 

 • I understand that this test uses a simple collection procedure of inserting a soft swab a short way into the nose or by collecting saliva samples. 

• I understand that there is the potential for a false positive or false negative COVID-19 test result, no matter the kind of testing being performed. 

• I agree to indemnify, defend and hold harmless the school, the screening testing vendor, the Alabama Department of Public Health and the University of Alabama at Birmingham, and all of their employees, officers, directors and trustees from any/all liabilities, claims or actions arising out of or related to the performance of this testing. 

• I understand that my child’s/student’s test results will be made available to me as parent/legal guardian through a secure data portal. 

• I understand that if my child/student has a positive test result, the testing staff will notify me directly via the preferred method of communication that I indicate below (example: email, text message). 

• I understand that all results will be reported individually to me as parent/legal guardian of the child/student named above, and individually by name and in aggregate to the Alabama Department of Public Health and to designated school officials whose roles include managing contacts of individuals carrying the COVID-19 virus. 

 • I understand that all results will be reported in aggregate to the University of Alabama at Birmingham program staff whose roles include providing management support for the testing program. 

• I understand that participation in COVID-19 testing may require the school to disclose my child’s/student’s identity, demographic, and contact information from education records to the testing provider and may require the school to disclose my child’s/student’s identity, demographic, and contact information from education records to the Alabama Department of Public Health. I authorize the school to disclose such personally identifiable information (PII) as is required for my child/student to participate in COVID-19 testing. By signing below, I attest that: Screening services provided by Luxor Scientific, LLC 

• I understand that this consent form will be valid for one year from the date of my execution of this consent unless I notify the designated contact person from my child’s/student’s school in writing that I revoke my consent. 

• I understand that authorizing these COVID-19 tests for my child/student is optional and that I can refuse to give this authorization, in which case, my child/student will not be tested. 

• I understand that I can change my mind and cancel this permission at any time, but that such cancellation is forward-looking only, and will not affect information previously released. To cancel this permission for COVID-19 testing, I need to contact the identified testing coordinator of the school my child/student attends. 

• I have been told that I can ask additional questions at any time. 

 • I have provided accurate and up-to-date contact information below.

Official Project Statement:

The UAB School of Public Health is currently collaborating with the Alabama Department of Public Health and the Alabama State Department of Education to offer voluntary asymptomatic COVID-19 testing in Alabama K-12 schools to students, faculty, and staff. The COVID Testing in Alabama K-12 Schools Program is fully funded by $147 million by the U.S. Department of Health and Human Services (HHS) Federal Funds. Learn more by visiting https://sites.uab.edu/covidalk12.